SOAP NOTE
Student Name: Course: NSG6420
Name: D.M. Date: 12/12/2023 Time: 0838
Ethnicity: African American Age: 51 Sex: M
SUBJECTIVE
CC: “I have been short of breath and ran out of my inhaler”
HPI: A 51-year-old male with a medical history of hypertension and asthma came in due to
shortness of breath. Patient was cooking over a hot stone stove yesterday and inhaled smoke,
which triggered his shortness of breath and cough. Patient ran out of rescue inhaler, so he
decided to come in for further management. Patient denies fever, chills, nausea, vomiting,
and weakness.
Medications: (list with reason for med )
Amlodipine 5mg Daily
PMH
Allergies: NKDA
Medication Intolerances: None
Chronic Illnesses/Major traumas: Hypertension, Asthma
Hospitalizations/Surgeries- Denies
Family History
M:
Hypertension
MGM:
unknown
MGF:
unknown F:
Hypertension
PGM:
, unknown
Student Name: Course: NSG6420
Name: D.M. Date: 12/12/2023 Time: 0838
Ethnicity: African American Age: 51 Sex: M
SUBJECTIVE
CC: “I have been short of breath and ran out of my inhaler”
HPI: A 51-year-old male with a medical history of hypertension and asthma came in due to
shortness of breath. Patient was cooking over a hot stone stove yesterday and inhaled smoke,
which triggered his shortness of breath and cough. Patient ran out of rescue inhaler, so he
decided to come in for further management. Patient denies fever, chills, nausea, vomiting,
and weakness.
Medications: (list with reason for med )
Amlodipine 5mg Daily
PMH
Allergies: NKDA
Medication Intolerances: None
Chronic Illnesses/Major traumas: Hypertension, Asthma
Hospitalizations/Surgeries- Denies
Family History
M:
Hypertension
MGM:
unknown
MGF:
unknown F:
Hypertension
PGM:
, unknown
