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Tony Stark / FNP594 Week 3 SOAP Note: Cardiac
Arrhythmia CC:, "I Have Been Having Palpitations
For A While, And Have Been Seeing A Cardiologist,
But They Were Getting Worse The Last Couple Of
Days." EXPERT FEEDBACK UPDATED 2023
FNP 594: Primary Care of Acute Clients/Families Across the Lifespan Week 3 SOAP
Note: Cardiac Arrhythmia
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Week 3 SOAP Note: Cardiac Arrhythmia
ID
Tony Stark, DOB 1/1/1954, age 66, is a widowed Caucasian male who appears to be a reliable
historian, presenting to the clinic by himself.
Subjective
CC: "I have been having palpitations for a while, and have been seeing a cardiologist, but they
were getting worse the last couple of days."
HPI
T.S. is a 66-year-old male presenting to the clinic alone with a complaint of palpitations that have
been increasing in intensity the last couple of days. The patient reports the palpitations started the
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, beginning of May and he has been seeing a cardiologist since the end of June for evaluation. The
patient reports he is pending insurance authorization for a ZIO monitor for assessment of
arrhythmias. Patient reports trying to make an appointment with his cardiologist today to report
worsening palpitations, but his cardiologist is on vacation until the end of next week. Patient
denies changes in diet, medication regimen, and regular routine. Denies shortness of breath and
chest pain, but reports feeling extra fatigued, lightheaded and dizzy with a 3/10 headache. Patient
reports taking Tylenol 650 mg PO prior to clinic appointment this morning.
Past Medical History: ●
Medical:
○ Hypotension
○ Hyperlipidemia (HLD)
○ Coronary artery disease
○ Osteoarthritis
● Surgeries:
○ CABG 2017
○ Cardiac Stents X4 2016
○ Right total knee replacement 2000
● Hospitalizations:
○ 2000- Right total knee replacement
○ 2016- Cardiac stents X4
○ 2017- CABG ○
2018- pneumonia
● Preventative care:
○ Moderna Covid Vaccine: 3/1/2020, 4/1/2020, 11/1/2020
○ Influenza vaccine: 11/1/2021
Allergies:
• No known drug allergies
Medications:
• Plavix 75 mg PO daily for cardiac stents
• Atorvastatin 20 mg PO before bedtime for HLD
• Multivitamin PO daily
• Tylenol 650 mg PO PRN 4-6 hours for pain
Social History:
• Denies alcohol, tobacco, and recreational drug use.
• Caffeine use o Reports drinking 1 cup of coffee daily.
• Exercise o Denies regular exercise routine.
• Employment
o Retired architect.
Tony Stark / FNP594 Week 3 SOAP Note: Cardiac
Arrhythmia CC:, "I Have Been Having Palpitations
For A While, And Have Been Seeing A Cardiologist,
But They Were Getting Worse The Last Couple Of
Days." EXPERT FEEDBACK UPDATED 2023
FNP 594: Primary Care of Acute Clients/Families Across the Lifespan Week 3 SOAP
Note: Cardiac Arrhythmia
2
Week 3 SOAP Note: Cardiac Arrhythmia
ID
Tony Stark, DOB 1/1/1954, age 66, is a widowed Caucasian male who appears to be a reliable
historian, presenting to the clinic by himself.
Subjective
CC: "I have been having palpitations for a while, and have been seeing a cardiologist, but they
were getting worse the last couple of days."
HPI
T.S. is a 66-year-old male presenting to the clinic alone with a complaint of palpitations that have
been increasing in intensity the last couple of days. The patient reports the palpitations started the
1
, beginning of May and he has been seeing a cardiologist since the end of June for evaluation. The
patient reports he is pending insurance authorization for a ZIO monitor for assessment of
arrhythmias. Patient reports trying to make an appointment with his cardiologist today to report
worsening palpitations, but his cardiologist is on vacation until the end of next week. Patient
denies changes in diet, medication regimen, and regular routine. Denies shortness of breath and
chest pain, but reports feeling extra fatigued, lightheaded and dizzy with a 3/10 headache. Patient
reports taking Tylenol 650 mg PO prior to clinic appointment this morning.
Past Medical History: ●
Medical:
○ Hypotension
○ Hyperlipidemia (HLD)
○ Coronary artery disease
○ Osteoarthritis
● Surgeries:
○ CABG 2017
○ Cardiac Stents X4 2016
○ Right total knee replacement 2000
● Hospitalizations:
○ 2000- Right total knee replacement
○ 2016- Cardiac stents X4
○ 2017- CABG ○
2018- pneumonia
● Preventative care:
○ Moderna Covid Vaccine: 3/1/2020, 4/1/2020, 11/1/2020
○ Influenza vaccine: 11/1/2021
Allergies:
• No known drug allergies
Medications:
• Plavix 75 mg PO daily for cardiac stents
• Atorvastatin 20 mg PO before bedtime for HLD
• Multivitamin PO daily
• Tylenol 650 mg PO PRN 4-6 hours for pain
Social History:
• Denies alcohol, tobacco, and recreational drug use.
• Caffeine use o Reports drinking 1 cup of coffee daily.
• Exercise o Denies regular exercise routine.
• Employment
o Retired architect.
