NUR 5153 FNP SOAP note new template

:Section 1 Patient Initials: J.A. Age: 58 y/o Gender: Male Race: Caucasian ”.Chief complaint: “I’ve been having some chest discomfort · :HPI · OLDCARTS o J.A. is a 58 y/o healthy man presenting to care provider with a o complaint of recent episodes of burning chest discomfort X 4 days. Rating substernal pain 4-5/10 at its worst, radiating into his neck. Current pain of 1-2/10. Borderline-obese. Well controlled HTN, on Lopressor, and borderline lipid abnormality. Recent stress concerns about the cost of college for his daughter. FH is significant for a father who died of a CVA at 85y/o and mother .with mild HTN PMH, PSH · :Past Medical Hx o Hypertension X 15 years, takes Lopressor 50mg PO QD; ▪ Borderline hyperlipidemia; Borderline obesity No prior surgeries/ hospitalizations ▪ Immunizations up to date ▪ Preventive Health: Colonoscopy at 56; Was supposed to be ▪ going to weight watcher for weight reduction, poor compliance; Was supposed to be exercising FH · Father: MI in his 50’s and 60’s; died of CVA at 85 y/o o Mother: Mild HTN, osteoporosis; alive- 77 y/o o Sister: no medical issues; alive - 52 y/o o PGF: died of MI at 65 y/o o SH · Married to second wife of 13 years o y/o step daughter 14 o Works in airplane maintenance, loves job o No smoking, no recreational drugs, no alcohol o Meds · Lopressor 50mg PO QD for high blood pressure o Allergies · NKDA o NKFA o NKLA o :Section 2 ROS · General: Denies fatigue or difficulty sleeping, denies weight loss o