SOAPM is used for EMS documentation.
(Sx) 65 Y/O M C/O of tightness in Cx and SOB. Pt’s spouse states, “John was mowing the lawn when he started to clutch his Cx and complain of not being able to breathe.” Pt states, “The pain is getting better, but my Cx feels tight and I can’t seem to catch my breath.” Pt also states, “I felt a sharp pain in my Cx and couldn’t breathe, so I stopped what I was doing and came inside to sit down.” Pt C/O Cx tightness and SOB. (-) to any numbness or tingling. Not taking any Rx other than OTC multivitamins qdx1. Allergic to Penicillin. Pt has no previous medical Hx and last oral intake was 2 hours ago. The pain started when pt was mowing the lawn and feels sharper when pt breathes in. Pain is otherwise dull and radiates out to entire Cx. Pain is 6/10 and started at appx. 1315.
(Ox) U/A we found pt sitting upright in a chair with spouse next to him. Pt A/Ox4. Appx. 1330, B/P 140/100, P 72, RR 23. Skin is pale, cool and diaphoretic. HEENT: C/O dizziness, (-) ear, neck, throat or eye pain. No evidence of trauma. Cx has equal rise/fall, L/S clear bilaterally, C/O dull chest pain. Abd is soft, non-tender and no masses. Pelvis is intact and no pain.
(Ax) Pt has a possible MI with onsent during physical activity.
(Px) Appx. 1331, pt placed on 02 @ 15lpm via NRB and IV 18G to L AC. Administered ASA 162mg chewable PO, NTG 0.4mg SL, and NTG ointment 1″ to L Cx. ECG Sinus tach @ 101 and stable. Pt transferred from couch to gurney with assistance and Tx to ACME Medical Center. Pt’s spouse followed in POV. Contacted ACME Medical Center to notify them of pt’s arrival and condition. No changes to pt’s condition en route. Pt care was transferred to Jane Doe, RN at ACME Medical Center at appx. 1358.
(Mx) Emergency Tx was necessary because pt is suspected to have a possible MI.