written by
Profmike
Joseph Camella "Shortness of Breath"
, SHORTNESS OF BREATH 2
Shortness of Breath
Institution Affiliation
Date:
Assignment 1
Episodic/Focused SOAP Note Template
SHORTNESS OF BREATH 3 Fam Hx: Father died at 80 of heart attack, mother at 75 from severe chest pain. No history of cardiovascular illnesses from other family members. ROS: GENERAL: five pond weight gain. Patient Information: MH, 68, Male, White American S. CC : “Shortness of Breath” HPI : The patient is 68 year old WA male with a shortness in breath. The shortness of breath is described to be experienced all the time and worsens at night. The shortness of br eath is accompanied by a cough that continues throughout eh night . The patient reports swelling in the abdomen and legs as well as an increase in w eight by fi v e pounds . The patient was prescribed fluid pill for the swelling. Current Medications : No medications . Allergies: No cases of allergies reported . PMHx : Positive medical history.
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