EYoung Cardiovascular SOAP Note Harvey Hoya Graded A+

EYoung Cardiovascular SOAP Note Harvey Hoya Graded A+ SOap Note Blue Print Course: NURS5102R50 Student: Emily Young Faculty: Dr. Tracy Collins Pt Initials: HH Age: 57 Race: Hispanic Sex: M New Pt: Y Established Pt: Info Source: Patient Reliability: Reliable E&M Code(s) I.10 S CC: Elevated blood pressure HPI: A 57-year-old Hispanic male presents to the clinic “I had my blood pressure checked at a health fair earlier and it was high, my wife convinced me to come in.” Patient describes a sedentary lifestyle and poor eating choices such as fast food multiple times per week that have resulted in recent weight gain. Patient describes “dull” headaches that “occur 2-3 times a week, usually beginning in the morning,” in which he takes Ibuprofen “about 4-5 pills per day,” as well as “not being able to sleep well, and feeling tired all day.” Wife is present this visit and states that at night, “he has periods of not breathing, and when she wakes him up he resumes sleep.” Pt. currently “works 5 days/week in construction.” Histories: PMH: Reports past medical history of “similar symptoms” and a “Dr. warning him of the importance of his high blood pressure and lifestyle choices a few years ago.” Pt. describes seeing no primary care since this occurrence, admits to not altering diet/exercise as he was advised to. Reports he is not up to date on current immunizations, no childhood illnesses. FH: Brother and uncle both diagnosed with HTN in mid and late 40’s, both “alive and well,” Paternal Grandfather deceased d/t MI at age 52., Father deceased d/t stroke at age 62. Mother alive with Diabetes. Med Hx: Ibuprofen taken when headaches occur, up to 4-5 pills per day. SH: Pt. reports smoking a pack per day “since his 20’s.” Denies use of drugs. Reports drinking beer “only on weekends.” Pt is married, lives with spouse and children, and works in construction. ROS: HEENT: Afebrile. Skin dry, warm, and intact. Pupils equal, round, reactive to light. Thyroid palpable, no enlargement noted. Cardiovascular: Elevated BP readings x2, laterally displaced PMI, denies chest pain. Respiratory: Respirations are even, unlabored. GI: Pt. is of overweight status. Describes high fat and high sodium diet of frequent fast food and TexMex style meals at home, daily coffee intake. Reports weight gain of more than 10 pounds within the last year. Neuro: Reports dull headaches that begin in the morning occurring 2-3 times per week.