Nursing 633 Week 4 SOAP Note- Tom Cardio

Nursing 633 Week 4 SOAP Note- Tom Cardio Week 4- SOAP Note Identifying data Name: Tom Jones Age: 36-years old Gender: Male Ethnicity: Hispanic S) CC: Fatigue, abdominal pain, nausea HPI: Tom has been feeling good and doing well on the treatment started a 1-year ago for his hypertension, COPD and DM2. He does not always remember to check his blood sugars on a daily basis. However, he does check several times a week and his blood sugar levels vary between 150- 170’s. He does not recall if he checks his blood sugars pre- or post- meals. He is busy with work and his family, especially now that his infant son is requiring more attention. Today he complains that for the last week, he has been having dizziness with palpitations, which give him a feeling of needing to catch his breath. He has not had syncope or pre-syncope events.