Cardiology SOAP Note Example: Severe Aortic Stenosis
A cardiology consult note: symptoms tied to exertion, cardiac risk factors, functional class, an exam that describes the murmur fully, and ECG and echo connected to the story.
By Francisco Sanchez, BSN, RN · ER nurse and FNP student · Updated October 2026
Setting: Outpatient cardiology consultationPatient: Fictional patient: 76-year-old man with hypertension and hyperlipidemia
SSubjective
Chief complaint
"I get winded walking to the mailbox." Referred for a new murmur.
HPI
6 months of progressive shortness of breath with exertion; now limited to about one block (walked a mile a year ago). Two episodes of chest pressure while walking uphill, lasting 2-3 minutes, relieved by rest, not radiating. Lightheaded once climbing stairs last month; no syncope. No orthopnea, paroxysmal nocturnal dyspnea, palpitations or leg swelling.
Risk factors
Hypertension, hyperlipidemia, former smoker (20 pack-years, quit 15 years ago). No diabetes. No family history of early coronary disease.
Functional capacity
NYHA class III: comfortable at rest, symptoms with less than ordinary activity.
Meds / allergies
Lisinopril 10 mg daily, atorvastatin 40 mg daily, aspirin 81 mg daily. No known drug allergies.
OObjective
Vital signs
BP 138/76 (right arm), HR 68 regular, RR 16, SpO2 97% on room air, BMI 27.
Exam
Heart: grade 3/6 harsh crescendo-decrescendo systolic murmur, loudest at the right upper sternal border, radiating to both carotids; single, soft S2; no S3. Point of maximal impulse sustained, not displaced. Carotids: delayed, diminished upstroke. JVP 7 cm H2O. Lungs clear. No peripheral edema. Radial pulses 2+.
ECG
Sinus rhythm at 68; left ventricular hypertrophy by voltage with repolarization changes. Compared with the ECG from 2 years ago, the LVH is new. No Q waves.
Severe, symptomatic aortic stenosis (exertional dyspnea, angina and presyncope) with preserved ejection fraction. Symptomatic severe aortic stenosis is an indication for valve replacement; outlook without it is poor. Exertional chest pressure may also reflect coronary disease given his risk factors, which needs evaluation before valve replacement. The murmur is not typical of hypertrophic cardiomyopathy (carotid upstroke is delayed, not brisk) or aortic sclerosis (significant gradient).
Risk stratification
Surgical risk (STS score) and frailty to be assessed by the heart valve team.
PPlan
Diagnostics
Coronary evaluation (coronary CT angiography or invasive angiography) and TAVR-protocol CT for valve sizing and access.
Treatment
Refer to the multidisciplinary heart valve team to decide between transcatheter and surgical valve replacement. Continue aspirin, atorvastatin and lisinopril; avoid overtreating blood pressure. No nitrates, given dependence on preload. Avoid strenuous exertion and dehydration. Dental evaluation before valve replacement.
Disposition / follow-up
Heart valve team visit within 2-4 weeks. Call 911 for fainting, chest pain at rest or lasting more than 15 minutes, or sudden worsening shortness of breath.
Fictional patient, written for learning. Follow your program's and facility's documentation standards.
Why this note works
The HPI ties each symptom to exertion and records functional class, which decides severity.
The murmur is described fully: grade, shape, location, radiation and the carotid upstroke.
The ECG is compared with a prior tracing, and the echo numbers support the diagnosis.
The Assessment explains why this matters now (symptomatic severe stenosis) and what else could explain the chest pressure.
What students often miss
Comparing the ECG with a prior one
Volume status in heart failure
Risk stratification in the Assessment
Cardiology SOAP note template
Characterize the symptom, weigh cardiac risk, and connect ECG and labs to the story.
Reading examples helps. Writing your own note and seeing exactly what you missed is what makes you better. SOAPy gives you a realistic case and checks your note section by section.