Soap note: acute myocardial infarction

(Student Name)

Miami Regional University

Date of encounter:

Preceptor/Clinical Site: __________

Clinical Instructor:

Soap Note # 1     Main Diagnosis: Acute Myocardial Infarction (ICD10 I21.0)

INFORMATION FOR PATIENTS

Name: __________

Age: __________

Gender at Birth: __________

Gender identity:

Source: __________

Allergies: __________

Current Medication:

PMH: __________

Immunizations: __________

Preventive Care:

The Surgical History of _________

Family History:

Social History:

Sexual orientation:

Nutrition History: __________

Subjective data:

Chief Complaint:

HPI/Symptom Analysis:

They are complaining of chest pain and shortness in breath. This patient is a smoker and has history of hypertension.

Review of Systems

CONSTITUTIONAL: __________

NEUROLOGIC: __________

HEENT: __________

RESPIRATORY: __________

CARDIOVASCULAR: __________

GASTROINTESTINAL: __________

GENITOURINARY: __________

MUSCULOSKELETAL: __________

SKIN: __________

Objective data:

VITAL SIGNS: __________

GENERAL APPEARANCE:

NEUROLOGIC: __________

HEENT: __________

CARDIOVASCULAR: __________

RESPIRATORY: __________

GASTROINTESTINAL: __________

MUSKULOSKELETAL: __________

INTEGUMENTARY: __________

ASSESSMENT:

Acute Myocardial Infarction (ICD10 I21.0) is the most common diagnosis.

Differential diagnosis:

  • ICD10 I20.0: Unstable angina
  • Acute Coronary Syndrome ICD10 I20.
  • Pulmonary Embolism – ICD10 I26.0

PLAN:

If applicable, Labs and Diagnostic Tests must be ordered

  • ECG
  • Tests of blood (including levels of troponin)

Pharmacological treatment

  • Aspirin
  • Nitroglycerin
  • Clopidogrel
  • ACE inhibitors
  • Beta Blockers

Non-Pharmacologic treatment:

  • Oxygen therapy
  • Referrals for cardiac catheterization

Education (provide the most pertinent ones that are tailored for you patient).

  • Important to eat a healthy diet
  • There are strategies to quit smoking
  • Prescribed medications explained
  • Follow-up appointments are important

Follow-ups/Referrals:

  • Within one week, follow-up visit with your primary care physician
  • Refer to a cardiologist for additional management

References (in APA Style

Codina Leik, M. T. (2014). Family Nurse Practitioner Certificate Intensive review (2nd edition). ISBN 9780-8261-3424

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