NURS 5220 SOAP NOTE ASSIGNMENT 1 COMPLETE
SOLUTION STUDY GUIDE LATEST VERSION
Chief Complaint (CC): "I can't catch my breath, my chest feels heavy, and my
legs are swelling up like balloons."
History of Present Illness (HPI): J.D. is a 68-year-old Caucasian male
presenting to the clinic with a 5-day history of progressively worsening
dyspnea on exertion (DOE), new-onset substernal chest heaviness, and
bilateral lower extremity edema.
• Onset: Symptoms began approximately 5 days ago after a large, salty
meal (canned soup and processed meats).
• Location: Dyspnea is central. Chest heaviness is substernal, radiating to
the left jaw and medial left arm.
• Duration: Dyspnea and edema are constant and worsening. Chest
heaviness is episodic, occurring 3–4 times daily, lasting 10–15 minutes
per episode.
• Characterization: Describes dyspnea as "air hunger." Describes chest
heaviness as "an elephant sitting on my chest," rated 6/10 at worst.
Edema is "tight and pitting."
• Aggravating Factors: Exertion (walking to the bathroom), lying flat
(orthopnea requiring 3 pillows), high sodium intake.
• Alleviating Factors: Rest partially alleviates dyspnea and chest pain.
Sitting upright helps breathing.
• Radiation: Chest discomfort radiates to the left jaw and left medial arm.
• Timing: Chest symptoms occur predictably with exertion.
• Severity: Dyspnea 7/10, Chest pain 6/10, Edema causing significant
discomfort and difficulty putting on shoes.
Associated Symptoms:
• Positive: Orthopnea (requires 3 pillows), Paroxysmal Nocturnal
Dyspnea (PND) x 2 nights ago, lower extremity edema up to the shins,
fatigue, weakness, nocturia (x3 per night), early satiety.
, • Negative: No documented fever, chills, cough, hemoptysis, palpitations,
syncope, dizziness, abdominal pain, melena, or focal neurological deficits.
Past Medical History (PMH):
1. Hypertension (HTN) x 15 years
2. Type 2 Diabetes Mellitus (T2DM) x 12 years
3. Hyperlipidemia x 10 years
4. Coronary Artery Disease (CAD) - Status post Percutaneous Coronary
Intervention (PCI) with stent to the LAD in 2018
5. Chronic Kidney Disease (CKD) Stage 3a (eGFR typically 45-55)
6. Benign Prostatic Hyperplasia (BPH)
7. Obesity
Past Surgical History (PSH):
1. PCI with bare-metal stent (LAD) - 2018
2. Colonoscopy with polypectomy - 2015
3. Motor Vehicle Accident - ORIF right tibia/fibula - 2005
Medications:
1. Metoprolol Succinate 50 mg PO daily
2. Lisinopril 20 mg PO daily
3. Amlodipine 5 mg PO daily
4. Aspirin 81 mg PO daily
5. Atorvastatin 40 mg PO daily
6. Metformin 1000 mg PO BID
7. Tamsulosin 0.4 mg PO QHS
8. OTC: Ibuprofen 400 mg PO TID for the past week for knee arthritis
pain.
Allergies:
• Penicillin - Causes rash (Anaphylaxis not documented, but avoided)
• Sulfa drugs - Causes hives
• NKDA (No Known Drug Allergies) otherwise.
SOLUTION STUDY GUIDE LATEST VERSION
Chief Complaint (CC): "I can't catch my breath, my chest feels heavy, and my
legs are swelling up like balloons."
History of Present Illness (HPI): J.D. is a 68-year-old Caucasian male
presenting to the clinic with a 5-day history of progressively worsening
dyspnea on exertion (DOE), new-onset substernal chest heaviness, and
bilateral lower extremity edema.
• Onset: Symptoms began approximately 5 days ago after a large, salty
meal (canned soup and processed meats).
• Location: Dyspnea is central. Chest heaviness is substernal, radiating to
the left jaw and medial left arm.
• Duration: Dyspnea and edema are constant and worsening. Chest
heaviness is episodic, occurring 3–4 times daily, lasting 10–15 minutes
per episode.
• Characterization: Describes dyspnea as "air hunger." Describes chest
heaviness as "an elephant sitting on my chest," rated 6/10 at worst.
Edema is "tight and pitting."
• Aggravating Factors: Exertion (walking to the bathroom), lying flat
(orthopnea requiring 3 pillows), high sodium intake.
• Alleviating Factors: Rest partially alleviates dyspnea and chest pain.
Sitting upright helps breathing.
• Radiation: Chest discomfort radiates to the left jaw and left medial arm.
• Timing: Chest symptoms occur predictably with exertion.
• Severity: Dyspnea 7/10, Chest pain 6/10, Edema causing significant
discomfort and difficulty putting on shoes.
Associated Symptoms:
• Positive: Orthopnea (requires 3 pillows), Paroxysmal Nocturnal
Dyspnea (PND) x 2 nights ago, lower extremity edema up to the shins,
fatigue, weakness, nocturia (x3 per night), early satiety.
, • Negative: No documented fever, chills, cough, hemoptysis, palpitations,
syncope, dizziness, abdominal pain, melena, or focal neurological deficits.
Past Medical History (PMH):
1. Hypertension (HTN) x 15 years
2. Type 2 Diabetes Mellitus (T2DM) x 12 years
3. Hyperlipidemia x 10 years
4. Coronary Artery Disease (CAD) - Status post Percutaneous Coronary
Intervention (PCI) with stent to the LAD in 2018
5. Chronic Kidney Disease (CKD) Stage 3a (eGFR typically 45-55)
6. Benign Prostatic Hyperplasia (BPH)
7. Obesity
Past Surgical History (PSH):
1. PCI with bare-metal stent (LAD) - 2018
2. Colonoscopy with polypectomy - 2015
3. Motor Vehicle Accident - ORIF right tibia/fibula - 2005
Medications:
1. Metoprolol Succinate 50 mg PO daily
2. Lisinopril 20 mg PO daily
3. Amlodipine 5 mg PO daily
4. Aspirin 81 mg PO daily
5. Atorvastatin 40 mg PO daily
6. Metformin 1000 mg PO BID
7. Tamsulosin 0.4 mg PO QHS
8. OTC: Ibuprofen 400 mg PO TID for the past week for knee arthritis
pain.
Allergies:
• Penicillin - Causes rash (Anaphylaxis not documented, but avoided)
• Sulfa drugs - Causes hives
• NKDA (No Known Drug Allergies) otherwise.
