SOAP Note Template

S: subjective

O: objective

A: assessment

P: plan

 S: 

No complaints.  Rested comfortably overnight.  Denies any further chest pain.  No SOB, PND, orthopnea, palpitations, nausea, vomiting, diaphoresis.

 O:           

PE: BP 120/85        P64       RR16       T98.6      O2sat 99% RA
Appears comfortable, well, no acute distress.
HEENT: NC/AT. Conjunctiva pink, no petechiae.  Oral pharynx w/o lesions.
Neck: Supple, no JVD.
Chest: Clear to auscultation bilaterally.  No rales, wheezing, rhonchi.
Cor: Regular S1, S2, without murmurs/rubs/gallops
Abd: NABS.  Soft, nontender, no masses, no HSM.
Extr: no cyanosis, clubbing, edema
Skin: warm and dry, no diaphoresis 

Labs:    6 AM FSBG  152
            #1  CK 150, CKMB 12, Troponin <0.010, Myoglobin 55
            #2  CK  130, CKMB 10, Troponin <0.010, Myoglobin 80
            #3 cardiac enzymes pending

                    CBC, lytes pending

 EKG (AM day #2):   NSR, 70, 0°, 0.18/0.11/0.35, no Q waves.  Normalization of T waves, changed from admission

 A/P:

  1. Chest pain---Unstable angina, possible acute coronary syndrome.  Symptoms initially relieved w SL nitroglycerin, no further symptoms.  ECG changes normalized, cardiac enzymes negative w normal total CK and troponin, and very slightly elevated CKMB.  Awaiting cardiac enzyme set #3.  Continue O2.  On ASA 81 mg po daily, Plavix 75 mg po daily, Lovenox 1 mg/kg q 12 hrs, Glycoprotein IIb/IIIa inhibitor per protocol.  Metoprolol increased to 50 mg po BID.  Also on simvastatin and lisinopril, and for SL NTG prn.  If enzyme set #3 is negative, will plan on ETT-Thallium today. 

  2. HTN---BP better, however diastolic slightly higher than desired.  Increase metoprolol to 75 mg po BID.  Lisinopril dose maintained at 20 mg po daily.

  3. DM---currently on sliding scale regular insulin.  AM FSBG 152. Cr normal at 0.8.  Will probably need adjustment of outpatient regimen prior to discharge.  Need to hold metformin if scheduled for cardiac cath.Diabetic diet.  Nutrition visit scheduled.

  4. Hyperlipidemia---simvastatin increased to 80 mg po q d.  Low cholesterol diet.  Nutrition visit scheduled.       

  5. Obesity---weight loss counseling.  Nutrition visit scheduled.

  6. Smoking---not interested in quitting smoking now, “too stressed.”  Temporarily wearing nicotine patch while hospitalized.

  7. GERD---asymptomatic. 

 

01.20.03, Rev 07.25.06