Cardiology SOAP Note Sample Report #1
SUBJECTIVE: The patient is an (XX)-year-old female known to us because of a history of mitral regurgitation and atrial fibrillation, status post mitral valve repair, history of diabetes, asthma, and recurrent chest discomfort with negative cardiac workup for coronary artery disease, who returned in followup visit. The patient was seen by us last in January of last year, and at that time, we felt that she was doing quite well from the cardiac standpoint and recommended the same medication and no further cardiac evaluation.
Since then, the patient has continued to experience occasional chest discomfort, but this time, the chest discomfort has been only lasting a few minutes. She has learned how to pace herself and even the dyspnea on exertion is much improved. In the office, she is quite pleasant, without distress, and no new symptoms. She also denied any recent hospitalization for cardiac-related issues. Current medications included CellCept 500 mg daily, Lasix 40 mg daily, potassium chloride 10 mEq daily, atenolol 50 mg daily, Singulair 10 mg daily, Coumadin, Lipitor 40 mg daily, and Zyrtec 10 mg daily. She is married and lives with her husband. No smoking. No alcohol.
OBJECTIVE: Blood pressure 104/72 with a pulse rate of 70 and weight of 140 pounds. HEENT/Neck: There is no JVD. There is a 2+ carotid. We do not appreciate a bruit. The lungs have reduced breath sounds, but they are clear to auscultation and percussion. Heart reveals irregularly irregular rhythm. S1 is slightly accentuated. The S2 is single. We do not appreciate a significant mitral regurgitation. No S3 or LV heave. The abdomen is soft, nontender, and nondistended. Extremities showed trace peripheral edema. There is no clubbing or cyanosis.
Electrocardiogram revealed an atrial fibrillation with a controlled ventricular response, heart rate around 70. T-wave inversion anteriorly, question ischemia and nonspecific ST-T changes inferiorly and laterally. Compared to previous study, there are no significant changes.
ASSESSMENT:
1. Mitral regurgitation, status post mitral valve repair.
2. Underlying preserved systolic function with recurrent atypical chest pain for angina pectoris.
3. Anxiety.
4. Hypertension.
PLAN:
1. Continue current medical regimen.
2. Encouraged to remain physically active.
3. No need for further cardiac workup.
4. Return in six to nine months.
Cardiology SOAP Note Sample Report #2
SUBJECTIVE: The patient is a (XX)-year-old male known to us because of a history of coronary artery disease and a CABG back in October, who returns for a followup visit. The patient was seen by us last in October of last year, and at that time, we felt he was doing quite well from the cardiac standpoint. We did repeat his lipid profile at that time, and total cholesterol was 160 with HDL of 68, LDL of 78, and triglycerides of 74. ALT showed normal value. The patient continued to report an excellent functional capacity. He does walk almost on a daily basis weather permitting. He denies any hospitalization for cardiac-related symptoms. No new symptoms. In particular, he denies any chest pain, PND, orthopnea, or peripheral edema. Current medications include lisinopril 5 mg every evening, amlodipine 5 mg every day, hydrochlorothiazide 12.5 mg daily, aspirin 325 mg daily, simvastatin 80 mg daily, metoprolol 50 mg p.o. b.i.d., omeprazole 20 mg as needed, and multivitamin.
OBJECTIVE: Blood pressure is 112/72 with a pulse rate of 78 and weight of 190 pounds. HEENT/Neck: There is no JVD, 2+ carotids. We do not appreciate a bruit. The lungs are clear to auscultation and percussion. Heart reveals a regular rate and rhythm with a normal S1 and S2. We cannot rule out soft S4. There is a faint systolic ejection murmur. The abdomen is distended but soft, nontender, and overall benign. The extremities show no peripheral edema. Neurological examination is grossly nonfocal.
DIAGNOSTIC DATA: Electrocardiogram revealed a normal sinus rate of 76 beats per minute with minor IVCD versus incomplete right bundle branch block. Cannot rule out an IMI compared to a prior EKG. No significant changes.
ASSESSMENT:
1. Coronary artery disease, status post coronary artery bypass graft.
2. Preserved systolic function.
3. Hypertension.
4. Anxiety.
PLAN:
1. Continue current medical regimen.
2. Encouraged to increase physical activity.
3. No need for further cardiac workup.
