(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