Write a SOAP note for a patient with unstable angina presenting with chest pressure radiating to the left arm and jaw at rest, lasting 5–10 minutes, partially relieved by nitroglycerin, accompanied by diaphoresis and shortness of breath, who has a history of hypertension, hyperlipidemia, and smoking and no prior myocardial infarction.

SOAP Note for Unstable Angina

Subjective

Chief Complaint: Chest pressure radiating to left arm and jaw at rest

History of Present Illness:

• Chest pain characteristics: Pressure-type discomfort, substernal, radiating to left arm and jaw
• Onset and duration: Occurring at rest, episodes lasting 5–10 minutes
• Quality: Pressure sensation (typical for acute coronary syndrome)
• Associated symptoms: Diaphoresis and shortness of breath
• Relieving factors: Partial relief with nitroglycerin 1
• Pattern: Rest angina consistent with unstable angina definition 2, 3

This presentation meets criteria for unstable angina—specifically rest angina, one of the three principal presentations of NSTE-ACS 4. The partial response to nitroglycerin does not rule out acute coronary syndrome, as relief with nitroglycerin has poor diagnostic specificity (37%) for differentiating cardiac from non-cardiac chest pain 5.

Past Medical History:

• Hypertension
• Hyperlipidemia
• Active smoking
• No prior myocardial infarction

Risk Factors Present:

• Male sex (implied by context)
• Smoking (active)
• Hypertension
• Hyperlipidemia
• These factors significantly increase probability of coronary artery disease 6

Medications: (Document current medications, particularly any antiplatelet agents, beta-blockers, statins, ACE inhibitors)

Objective

Vital Signs: (Document blood pressure, heart rate, respiratory rate, oxygen saturation, temperature)

Physical Examination:

• General appearance: Assess for distress, diaphoresis
• Cardiovascular: Heart sounds (S3/S4 gallop suggesting heart failure increases risk), murmurs, jugular venous distension
• Pulmonary: Crackles suggesting pulmonary edema (sign of heart failure, high-risk feature) 6
• Extremities: Peripheral edema, peripheral pulses

Critical point: Physical examination may be normal in NSTE-ACS, but signs of heart failure should expedite diagnosis and treatment 6.

12-Lead ECG (obtained within 10 minutes of arrival) 6:

• Look for: ST-segment depression, transient ST-elevation, or new T-wave inversion
• Persistent ST-segment depression indicates high-risk features 7
• Document any dynamic changes

Laboratory Studies:

• Cardiac troponin: Elevated troponin indicates high risk and defines NSTEMI vs unstable angina 6
• Complete blood count: Rule out anemia as secondary cause
• Basic metabolic panel: Assess renal function, electrolytes (hypophosphatemia can contribute to vasospasm 8)
• Lipid panel
• Chest X-ray: Evaluate for heart failure, alternative diagnoses (widened mediastinum for aortic dissection) 6

Assessment

Primary Diagnosis: Unstable Angina (NSTE-ACS)

Risk Stratification: High-risk features to assess 7, 6:

• Persistent ST-segment depression
• Elevated troponin level
• Persistent ischemic pain despite therapy
• Signs of heart failure
• Hemodynamic instability

This patient requires immediate intensive medical therapy and early invasive strategy if high-risk features present.

Differential Diagnoses to Consider 6:

• NSTEMI (if troponin elevated)
• Aortic dissection (consider if pain is tearing, radiates to back)
• Pulmonary embolism
• Pericarditis
• Esophageal spasm
• Musculoskeletal pain

Plan

Immediate Management (Emergency Department/Hospital Admission)

1. Hospital Admission with Continuous Monitoring 3

• Admit to coronary care unit or telemetry unit
• Continuous ECG monitoring and defibrillation capability
• Serial ECGs and cardiac biomarkers

2. Antiplatelet Therapy 7

• Aspirin 162-325 mg chewed immediately (if not already given), then 81 mg daily maintenance 7
• P2Y12 inhibitor: Loading dose of ticagrelor (180 mg), prasugrel (60 mg if proceeding to PCI and no high bleeding risk), or clopidogrel (300-600 mg) 7
  • Ticagrelor is reasonable in preference to clopidogrel for early invasive or ischemia-guided strategy 7

3. Anticoagulation 7

• Unfractionated heparin or low-molecular-weight heparin (enoxaparin)
• Continue until revascularization or hospital discharge

4. Anti-Ischemic Therapy

Nitroglycerin 1:

• Sublingual nitroglycerin 0.3-0.4 mg every 5 minutes for up to 3 doses 1
• If pain persists after 3 tablets in 15 minutes, this constitutes a medical emergency requiring immediate intervention 1
• Transition to intravenous nitroglycerin for ongoing or recurrent ischemia 4
• Caution: Monitor blood pressure; avoid if systolic BP <90 mmHg

Beta-Blockers 9:

• Initiate oral beta-blocker (e.g., metoprolol 25-50 mg twice daily) unless contraindicated
• Contraindications: decompensated heart failure, bradycardia, hypotension, reactive airway disease

5. Statin Therapy 9

• High-intensity statin (e.g., atorvastatin 80 mg daily) regardless of baseline LDL
• Reduces mortality and MI risk

6. ACE Inhibitor 9

• Initiate if hypertension, diabetes, or left ventricular dysfunction present
• Proven mortality benefit in coronary artery disease

Risk-Stratified Approach

If High-Risk Features Present (persistent ST depression, elevated troponin, ongoing pain, heart failure signs):

• Early invasive strategy with coronary angiography within 24-48 hours 7
• Add GP IIb/IIIa inhibitor (eptifibatide or tirofiban) if proceeding to PCI 7

If Intermediate/Low Risk:

• Ischemia-guided strategy with stress testing after stabilization
• Medical management with close monitoring

Patient Education and Discharge Planning (When Stable)

7. Discharge Medications 7

• Aspirin 81 mg daily indefinitely 7
• P2Y12 inhibitor (ticagrelor, prasugrel, or clopidogrel) for 12 months minimum if stent placed 7
• Beta-blocker continued long-term 9
• High-intensity statin 9
• ACE inhibitor 9
• Sublingual nitroglycerin for home use with instructions 7

8. Nitroglycerin Instructions 7, 1:

• "If angina lasts >1 minute, take 1 nitroglycerin dose sublingual or spray"
• "If pain does not subside within 3-5 minutes, call 9-1-1 immediately" 7
• Do not wait to take all 3 doses before calling emergency services
• May use prophylactically 5-10 minutes before activities that might precipitate angina 1

9. Warning Signs Education 7 Instruct patient to seek immediate emergency care if:

• Chest pain more frequent, severe, or occurs with less exertion
• Pain at rest
• Pain lasting >5 minutes despite nitroglycerin
• Associated symptoms: severe shortness of breath, diaphoresis, nausea, lightheadedness

10. Risk Factor Modification 7

• Smoking cessation: Mandatory—refer to cessation program
• Blood pressure control (target <130/80 mmHg)
• Diabetes management (if present)
• Cardiac rehabilitation referral
• Dietary counseling (Mediterranean diet, low saturated fat)
• Regular exercise program after clearance

11. Follow-Up

• Cardiology follow-up within 1-2 weeks of discharge
• Primary care follow-up for risk factor management
• Repeat lipid panel in 4-6 weeks to assess statin efficacy

Critical Pitfalls to Avoid

• Do not discharge without objective cardiac evaluation (ECG, troponins, risk stratification)
• Do not rely on nitroglycerin response to diagnose or exclude ACS 5
• Do not delay aspirin or antiplatelet therapy while awaiting test results
• Do not use short-acting dihydropyridine calcium channel blockers (e.g., immediate-release nifedipine)—these increase adverse cardiac events 9
• Recognize atypical presentations: Over 50% of elderly patients may present atypically with dyspnea, nausea, or fatigue rather than classic chest pain 10
• Women, diabetics, and elderly patients frequently have atypical symptoms 3, 6