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)

PATIENT INFORMATION

Name: __________

Age: __________

Gender at Birth: __________

Gender Identity: __________

Source: __________

Allergies: __________

Current Medications: __________

PMH: __________

Immunizations: __________

Preventive Care: __________

Surgical History: __________

Family History: __________

Social History: __________

Sexual Orientation: __________

Nutrition History: __________

Subjective Data:

Chief Complaint: __________

Symptom analysis/HPI:

The patient is reporting chest pain and shortness of breath. They have a history of hypertension and smoking.

Review of Systems (ROS)

CONSTITUTIONAL: __________

NEUROLOGIC: __________

HEENT: __________

RESPIRATORY: __________

CARDIOVASCULAR: __________

GASTROINTESTINAL: __________

GENITOURINARY: __________

MUSCULOSKELETAL: __________

SKIN: __________

Objective Data:

VITAL SIGNS: __________

GENERAL APPEARANCE: __________

NEUROLOGIC: __________

HEENT: __________

CARDIOVASCULAR: __________

RESPIRATORY: __________

GASTROINTESTINAL: __________

MUSKULOSKELETAL: __________

INTEGUMENTARY: __________

ASSESSMENT:

Main Diagnosis: Acute Myocardial Infarction (ICD10 I21.0)

Differential diagnosis:

• Unstable Angina (ICD10 I20.0)
• Acute Coronary Syndrome (ICD10 I20.1)
• Pulmonary Embolism (ICD10 I26.0)

PLAN:

Labs and Diagnostic Test to be ordered (if applicable)

• ECG
• Blood work (including troponin levels)

Pharmacological treatment:

• Aspirin
• Nitroglycerin
• Clopidogrel
• ACE inhibitors
• Beta blockers

Non-Pharmacologic treatment:

• Oxygen therapy
• Referral for cardiac catheterization

Education (provide the most relevant ones tailored to your patient)

• Importance of following a heart-healthy diet
• Strategies for quitting smoking
• Explanation of medications prescribed
• Importance of follow-up appointments

Follow-ups/Referrals:

• Follow-up appointment with primary care physician within one week
• Referral to cardiologist for further management

References (in APA Style)

Codina Leik, M. T. (2014). Family Nurse Practitioner Certification Intensive Review (2nd ed.). ISBN 978-0-8261-3424