Acute Chest Pain: Assessing for Acute Coronary Syndrome Introduction.Soap Note 1 Acute Conditions Follow the MRU Soap Note Rubric as a guide: Use APA format and must include minimum of 2 Scholarly Citations.

QUESTION

Soap Note 1 Acute Conditions

Follow the MRU Soap Note Rubric as a guide:

Use APA format and must include minimum of 2 Scholarly Citations.

Soap notes will be uploaded to Moodle and put through TURN-It-In (anti-Plagiarism program)

Turn it in Score must be less than 50% or will not be accepted for credit, must be your own work and in your own words. You can resubmit, Final submission will be accepted if less than 50%. Copy paste from websites or textbooks will not be accepted or tolerated. Please see College Handbook with reference to Academic Misconduct Statement.

Must use the sample templates for your soap note, keep this template for when you start clinicals.

ANSWER

Acute Chest Pain: Assessing for Acute Coronary Syndrome

Introduction

Acute chest pain is a common presentation in healthcare settings and requires prompt evaluation to determine the underlying cause and initiate appropriate treatment. This paper discusses a case of a 45-year-old male presenting with acute chest pain and outlines the subjective and objective findings, assessment, and plan for further evaluation and management. The SOAP (Subjective, Objective, Assessment, and Plan) note format is used to structure the discussion.

Subjective

The patient reports sudden onset of sharp, stabbing chest pain on the left side, radiating to the left arm. The intensity of the pain is rated as 8 out of 10, and it is exacerbated by deep breathing and movement. The patient expresses anxiety and concern about a possible heart attack. There is no previous history of chest pain or cardiac issues.

Objective

Vital signs indicate an elevated blood pressure of 140/90 mmHg and a heart rate of 100 beats per minute. The patient appears uncomfortable and diaphoretic. Physical examination reveals clear lung sounds, regular heart sounds, and no edema or cyanosis. The patient’s skin is warm and dry.

Assessment

Based on the patient’s symptoms and presentation, the primary assessment suggests a possible acute coronary syndrome, such as angina or myocardial infarction. The sudden onset of chest pain, radiation to the left arm, and exacerbation with movement raise concerns for a cardiac origin. Further evaluation and diagnostic testing are necessary to confirm the diagnosis and determine appropriate management.

Plan

A 12-lead electrocardiogram (ECG) will be obtained to assess for any cardiac abnormalities and changes consistent with myocardial infarction.
Sublingual nitroglycerin will be administered to alleviate chest pain and improve coronary blood flow if blood pressure remains stable.
Oxygen therapy will be initiated via nasal cannula to ensure adequate oxygenation.
An intravenous line will be started for potential medication administration and fluid resuscitation if necessary.
A cardiac enzyme panel (troponin levels) will be obtained to assess for myocardial damage.
A consultation with a cardiologist will be considered for further evaluation and potential cardiac catheterization.
Patient education will be provided regarding the signs and symptoms of a heart attack and the importance of seeking immediate medical attention in case of recurrence or worsening symptoms.

Follow-Up

A follow-up appointment will be scheduled in 2-3 days to review the results of diagnostic tests, monitor the patient’s condition, and adjust the treatment plan accordingly.

Conclusion

Acute chest pain is a critical symptom that requires a systematic approach to evaluation and management. Prompt assessment, including ECG, nitroglycerin administration, oxygen therapy, and laboratory investigations, is essential in determining the underlying cause and initiating appropriate treatment. Collaboration with a cardiologist ensures comprehensive evaluation and timely interventions. By understanding the data gathered from diagnostic tests, healthcare providers can make informed decisions and provide optimal care to patients experiencing acute chest pain.

References

American College of Cardiology Foundation Task Force on Clinical Expert Consensus Documents. (2012). Chronic stable angina. Journal of the American College of Cardiology, 60(23), e44-e164. doi: 10.1016/j.jacc.2012.07.013
2. Amsterdam, E. A., Wenger, N. K., Brindis, R. G., Casey, D. E., Ganiats, T. G., Holmes, D. R., … & Smith Jr, S. C. (2014). 2014 AHA/ACC guideline for the management of patients with non-ST-elevation acute coronary syndromes: Executive summary: A report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. Circulation, 130(25), 2354-2394. doi: 10.1161/CIR.0000000000000133