SOAP NOTE
Student Name: Course: NSG6420
Name: Date: 12/07/2023 Time: 1300
Ethnicity: White Age: 73 Sex: M
SUBJECTIVE
CC: “I’m have been having palpitations since waking this morning”
HPI: A 73-year-old Caucasian male patient arrives at the office, describing a sudden onset
of palpitations that woke him from sleep. The patient denies chest pain, but expresses
discomfort due to the palpitations. Additionally, he reports mild shortness of breath,
particularly exacerbated during exertion.
Medications: (list with reason for med )
Glimipiride 5 mg daily -Diabetes
Lisinipril 40mg once a day- Hypertension
Atorvastatin 40mg once a day- Hyperlipidemia
Tamsulosin 0.4mg daily
PMH
Allergies: NKDA
Medication Intolerances: None
Chronic Illnesses/Major traumas: hypertension, hyperlipidemia, Diabetes, BPH
Hospitalizations/Surgeries- Colonoscopy, endoscopy, lumbar surgery, cataract
Family History
M: Deceased- Cardiac
MGM: Deceased-
unknown
, MGF: Deceased- unknown F: Deceased lung cancer PGM: deceased- unknown PGF
deceased- unknown
Social History
Patient is a retired military veteran. He is married with 3 living kids. Patient is a former
smoker, denies alcohol use or substance abuse.
ROS
General Cardiovascular
Patient denies night sweats, fatigue or weakness Denies any chest pain or shortness of
breath, reports palpitations
Skin Respiratory
No rash, lesions, or other skin abnormalities Reports dyspnea denies cough.
Eyes Gastrointestinal
Denies any visual changes, complains of pain Denies abdominal pain, nausea, vomiting or
behind bilateral eyes diarrhea
Ears Genitourinary/Gynecological
Denies ear pain or hearing loss Denies discharge, dysuria hematuria.
Student Name: Course: NSG6420
Name: Date: 12/07/2023 Time: 1300
Ethnicity: White Age: 73 Sex: M
SUBJECTIVE
CC: “I’m have been having palpitations since waking this morning”
HPI: A 73-year-old Caucasian male patient arrives at the office, describing a sudden onset
of palpitations that woke him from sleep. The patient denies chest pain, but expresses
discomfort due to the palpitations. Additionally, he reports mild shortness of breath,
particularly exacerbated during exertion.
Medications: (list with reason for med )
Glimipiride 5 mg daily -Diabetes
Lisinipril 40mg once a day- Hypertension
Atorvastatin 40mg once a day- Hyperlipidemia
Tamsulosin 0.4mg daily
PMH
Allergies: NKDA
Medication Intolerances: None
Chronic Illnesses/Major traumas: hypertension, hyperlipidemia, Diabetes, BPH
Hospitalizations/Surgeries- Colonoscopy, endoscopy, lumbar surgery, cataract
Family History
M: Deceased- Cardiac
MGM: Deceased-
unknown
, MGF: Deceased- unknown F: Deceased lung cancer PGM: deceased- unknown PGF
deceased- unknown
Social History
Patient is a retired military veteran. He is married with 3 living kids. Patient is a former
smoker, denies alcohol use or substance abuse.
ROS
General Cardiovascular
Patient denies night sweats, fatigue or weakness Denies any chest pain or shortness of
breath, reports palpitations
Skin Respiratory
No rash, lesions, or other skin abnormalities Reports dyspnea denies cough.
Eyes Gastrointestinal
Denies any visual changes, complains of pain Denies abdominal pain, nausea, vomiting or
behind bilateral eyes diarrhea
Ears Genitourinary/Gynecological
Denies ear pain or hearing loss Denies discharge, dysuria hematuria.
