Chest pain
Complete SOAP example
Example narrative
64-year-old man from HOME, independent at baseline, reports central pressure-like chest pain beginning at 0910 while shovelling, radiating to the left arm with diaphoresis and nausea. Denies pleuritic pain or trauma. History includes hypertension and dyslipidemia.
Primary survey intact. Patient found seated at kitchen table, pale and diaphoretic. Serial vitals obtained; lungs clear and chest non-tender. Serial 12-leads obtained and monitored; measured findings communicated in pre-alert.
Differential considerations: 1) acute coronary syndrome, 2) aortic pathology, 3) gastrointestinal or esophageal pain. Ongoing high-risk chest pain without current hemodynamic instability.
Cardiac monitoring established. ASA and other care provided per current applicable guideline after contraindication screening. Pain and hemodynamics reassessed after interventions. Transported priority to appropriate ED; pre-alert completed and care transferred with ECGs and medication times.