Running head: EPISODIC SOAP NOTE: HAROLD JAMES 1
Episodic SOAP Note: Harold James
Lee Arthur
NRP 531
Professor Sandra Brown
, EPISODIC SOAP NOTE: HAROLD JAMES 2
DOS: 4/29/2019
ID: Harold James (M)
DOB: 6/28/47 (72)
CC: Otitis Externa and TIA
Subjective
HPI: Harold James is a 72-year-old African American male deemed a poor historian
presenting with complaints of otitis externa and TIA. Patient is accompanied by his daughter
who provides history. Harold’s daughter who talks with the patient daily reports that she noticed
that her father has become increasingly forgetful and does not recall conversations they had
earlier in the day and is concerned about memory loss. The patient’s daughter states she
witnessed Harold have an episode in which he stared at her and of slurred speech lasting 30
seconds a few days ago. Harold’s daughter denies history of seizures, recent surgery, previous
stroke or TIA’s, systemic or central nervous system infections and migraines. Harold also
complains of worsening pain in his left ear over the past week which he rates 10/10 severity
which he reports he cannot lay on the left side due to pain and denies loss of hearing. Harold’s
daughter noticed the opening of the left ear to be swollen with yellowish-tan drainage which she
accounts for his aggressive use of cotton swabs. Harold’s daughter reports that he has not been
compliant with medications since the weekly medication container has days that have been
skipped. Harold verbalizes to his daughter that he tries to remember to take them. Harold denies
chest pain, shortness of breath, urinary complaints, abdominal pain and rashes.
Episodic SOAP Note: Harold James
Lee Arthur
NRP 531
Professor Sandra Brown
, EPISODIC SOAP NOTE: HAROLD JAMES 2
DOS: 4/29/2019
ID: Harold James (M)
DOB: 6/28/47 (72)
CC: Otitis Externa and TIA
Subjective
HPI: Harold James is a 72-year-old African American male deemed a poor historian
presenting with complaints of otitis externa and TIA. Patient is accompanied by his daughter
who provides history. Harold’s daughter who talks with the patient daily reports that she noticed
that her father has become increasingly forgetful and does not recall conversations they had
earlier in the day and is concerned about memory loss. The patient’s daughter states she
witnessed Harold have an episode in which he stared at her and of slurred speech lasting 30
seconds a few days ago. Harold’s daughter denies history of seizures, recent surgery, previous
stroke or TIA’s, systemic or central nervous system infections and migraines. Harold also
complains of worsening pain in his left ear over the past week which he rates 10/10 severity
which he reports he cannot lay on the left side due to pain and denies loss of hearing. Harold’s
daughter noticed the opening of the left ear to be swollen with yellowish-tan drainage which she
accounts for his aggressive use of cotton swabs. Harold’s daughter reports that he has not been
compliant with medications since the weekly medication container has days that have been
skipped. Harold verbalizes to his daughter that he tries to remember to take them. Harold denies
chest pain, shortness of breath, urinary complaints, abdominal pain and rashes.
