Cardiovascular SOAP Note Example

Below is a nursing SOAP note for a cardiovascular examination based on a case study, incorporating all applicable components and subcomponents, and utilizing the OLDCART acronym in the History of Present Illness (HPI) section:

Review: Other Nursing SOAP Notes Examples

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• HEENT SOAP Note Example
• Respiratory SOAP Note Example
• Abdominal SOAP Note Example
• Musculoskeletal SOAP Note Example
• Neurological SOAP Note Example
• Skin, Hair, and Nails SOAP Note Example
• Discharge SOAP Note Example

Subjective:

1. Chief Complaint: Patient reports chest pain and shortness of breath.
2. HPI (History of Present Illness):
   • Onset: The patient states that the symptoms started abruptly yesterday evening.
   • Location: The patient reports experiencing the chest pain in the center of their chest, radiating to their left arm.
   • Duration: The patient mentions that the symptoms have been persistent since their onset.
   • Character: The patient describes the chest pain as a squeezing, pressure-like sensation. They report feeling breathless and fatigued with minimal exertion.
   • Aggravating Factors: The patient reports that the chest pain worsens with physical activity or when under emotional stress.
   • Relieving Factors: The patient states that resting and taking nitroglycerin sublingually provide temporary relief of the chest pain.
   • Treatment/Interventions Tried: The patient has been using nitroglycerin as prescribed for angina relief.
3. Past Medical History: Document any relevant past medical conditions, surgical procedures, or chronic cardiovascular illnesses that may be related to the current symptoms. Include details about any previous myocardial infarction, heart failure, or other cardiac conditions.
4. Family Medical History: Inquire about any family history of cardiovascular diseases, including myocardial infarction, angina, or other relevant conditions. Note any patterns of similar symptoms or early onset of cardiac problems among immediate family members.
5. Social History: Explore the patient’s lifestyle habits, including smoking history, alcohol consumption, and exercise routines. Assess any history of occupational or environmental exposures that may contribute to cardiovascular risk factors.
6. Medication History: Record the patient’s current and past medication history, including prescribed cardiac medications, antihypertensives, and any over-the-counter supplements they may be taking.
7. Allergy History: Inquire about any known allergies to medications, including cardiovascular medications or substances used during cardiac procedures. Note the type of reaction experienced and any known allergens to avoid.
8. Review of Systems: Conduct a brief review of systems, focusing on symptoms related to the cardiovascular system. Inquire about associated symptoms such as palpitations, dizziness, swelling of the extremities, or changes in urine output.

Objective:

1. Vital Signs: Blood pressure: 140/90 mmHg, Heart rate: 88 bpm, Respiratory rate: 18 breaths per minute, Temperature: 36.8°C.
2. General Appearance: The patient appears in mild distress, with slight shortness of breath and mild pallor.
3. Cardiovascular Examination: Regular heart rhythm, normal S1 and S2 heart sounds, no murmurs or extra heart sounds, no peripheral edema.

Assessment:

1. Medical Diagnosis: Acute coronary syndrome (unstable angina).
2. Problem Identification: Patient reports chest pain, shortness of breath, and fatigue.
3. Relevant Findings and Abnormalities: Presence of chest pain, radiating to the left arm, relieved by nitroglycerin.
4. Client Education Needs: Patient requires education on angina management, lifestyle modifications, and recognizing signs of worsening symptoms.

Plan:

1. Medical Interventions:
   • Administer aspirin and sublingual nitroglycerin as prescribed for acute symptom relief.
   • Order an electrocardiogram (ECG) to evaluate the patient’s cardiac rhythm and ischemic changes.
   • Consult with a cardiologist for further evaluation and consideration of invasive or non-invasive cardiac procedures.
2. Patient Education:
   • Educate the patient about angina triggers and the importance of managing cardiovascular risk factors.
   • Discuss the importance of adhering to prescribed medications, lifestyle modifications, and follow-up appointments.
   • Provide information on cardiac rehabilitation programs and resources for support.
3. Referrals or Consultations:
   • Refer the patient to a registered dietitian for guidance on a heart-healthy diet.
   • Consult with a cardiac rehabilitation specialist for long-term management and exercise program recommendations.
4. Safety Measures:
   • Assess the patient’s home environment for any potential hazards or barriers to self-care.
   • Provide education on when to seek immediate medical attention for worsening symptoms.
5. Evaluation:
   • Schedule a follow-up appointment with a cardiologist in one week to assess response to treatment and adjust the management plan if needed.
   • Monitor for any signs of worsening symptoms or new cardiovascular complications.

• This example demonstrates a cardiovascular SOAP note based on a case study, incorporating all applicable components and subcomponents.
• The subjective section captures the patient’s chief complaint and provides a detailed HPI using the OLDCART acronym.
• The objective section includes vital signs and examination findings related to the cardiovascular system.
• The assessment section includes the medical diagnosis, relevant findings, and problem identification.
• The plan outlines the medical interventions, patient education, referrals or consultations, safety measures, and a plan for evaluation.