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Clinical Notes

All SOAP Discharge Progress
SOAP Note — Grace Kamau Subjective: Patient presents with... Cardiology · 2 hr ago
Discharge — Peter Oloo Patient stabilized after... Emergency · 5 hr ago
Progress — Mary Wanjiku Day 3 post-operative... Surgery · 8 hr ago
SOAP Note — John Mwangi Chief complaint: Persistent... Internal Medicine · 1 day ago

SOAP Note — Grace Kamau

Original Clinical Text
S Subjective

Patient presents with recurring chest pain, described as pressure-like sensation radiating to the left arm. Pain onset 3 days ago, worsening with physical exertion. Reports shortness of breath and occasional dizziness. No history of similar episodes. Family history of coronary artery disease (father, age 58).

O Objective

BP 145/92 mmHg, HR 88 bpm, RR 18, SpO2 97% on room air. Temp 36.8°C. Cardiac auscultation reveals regular rhythm, no murmurs or gallops. Lungs clear bilaterally. ECG shows ST-segment changes in leads II, III, aVF. Troponin I: 0.04 ng/mL (borderline).

A Assessment

Hypertensive crisis with suspected unstable angina. Rule out acute coronary syndrome. Elevated cardiovascular risk given family history and current presentation.

P Plan

Start Amlodipine 5mg daily. Order stress echocardiogram and serial troponins q6h. Cardiology consult for further evaluation. Patient counseled on lifestyle modifications including dietary sodium restriction and moderate exercise. Follow-up in 48 hours.

NLP Analysis
Extracted Entities
Hypertensive crisis Unstable angina Coronary artery disease Amlodipine 5mg BP 145/92 HR 88 bpm SpO2 97% Stress echocardiogram Serial troponins ECG
ICD-10 Codes
I16.1
Hypertensive emergency
98.4%
I20.0
Unstable angina
96.1%
I25.1
Atherosclerotic heart disease
87.3%