1
Cardiovascular SOAP
Subjective
Identifying Data & Reliability
• Tina Jones. 28-year-old African American female.
• Source and reliability: Patient herself who seems reliable.
• Date of service: 10/15/2024
Chief Complaint
“I've been noticing my heart seems to be beating too fast every once in a while lately, and it
started to worry me.”
History of Present Illness
28-year-old female who presents with 3-4 episodes of palpitations over the past month.
She reports a rapid heart rate with a “thumping” feeling in her chest lasting 5-10 minutes
accompanied by anxiety. She notices the palpitations more in the morning after wakening and
denies any relieving factors besides deep breathing and relaxing. The patient has not taken any
medications to relieve symptoms. She denies any accompanying symptoms of chest pain,
dizziness, lightheadedness, syncope, nausea or vomiting. She reports an increase in caffeine use,
including the consumption of daily energy drinks and diet coke. The patient also reports starting
Flovent inhaler for her asthma, coinciding with the onset of symptoms one month ago. Flovent
has been effective in managing her asthma symptoms. She uses Flovent as prescribed, two puffs
twice a day. She denies any cardiac history and reports never having had a cardiac procedure or
EKG. The patient reports feelings of anxiety during times of increased stress from work and
school also coinciding with her symptoms.
Medications
Downloaded by Great Mind ()
Cardiovascular SOAP
Subjective
Identifying Data & Reliability
• Tina Jones. 28-year-old African American female.
• Source and reliability: Patient herself who seems reliable.
• Date of service: 10/15/2024
Chief Complaint
“I've been noticing my heart seems to be beating too fast every once in a while lately, and it
started to worry me.”
History of Present Illness
28-year-old female who presents with 3-4 episodes of palpitations over the past month.
She reports a rapid heart rate with a “thumping” feeling in her chest lasting 5-10 minutes
accompanied by anxiety. She notices the palpitations more in the morning after wakening and
denies any relieving factors besides deep breathing and relaxing. The patient has not taken any
medications to relieve symptoms. She denies any accompanying symptoms of chest pain,
dizziness, lightheadedness, syncope, nausea or vomiting. She reports an increase in caffeine use,
including the consumption of daily energy drinks and diet coke. The patient also reports starting
Flovent inhaler for her asthma, coinciding with the onset of symptoms one month ago. Flovent
has been effective in managing her asthma symptoms. She uses Flovent as prescribed, two puffs
twice a day. She denies any cardiac history and reports never having had a cardiac procedure or
EKG. The patient reports feelings of anxiety during times of increased stress from work and
school also coinciding with her symptoms.
Medications
Downloaded by Great Mind ()
