CV SOAP Note for Tina Jones - Cardiovascular Assessment

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CV SOAP Note for Tina Jones - Cardiovascular Assessment

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Institution CV SOAP Note For Tina Jones - Cardiovascular Asses

Course CV SOAP Note for Tina Jones - Cardiovascular Asses

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CV SOAP Note for Tina Jones - Cardiovascular Assessment

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Cardiovascular SOAP sr

Subjective

Identifying Data & Reliability sr sr sr

• Tina Jones. 28-year-old African American female.
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• Source and reliability: Patient herself who seems reliable.
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• Date of service: 10/15/2024
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Chief Complaint sr

“I've been noticing my heart seems to be beating too fast every once in a while lately, and it started
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r to worry me.”
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History of Present Illness sr sr sr

28-year-old female who presents with 3-4 episodes of palpitations over the past month.
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She reports a rapid heart rate with a “thumping” feeling in her chest lasting 5-
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10 minutes accompanied by anxiety. She notices the palpitations more in the morning after wake
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ning and denies any relieving factors besides deep breathing and relaxing. The patient has not tak
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en any medications to relieve symptoms. She denies any accompanying symptoms of chest pain,
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dizziness, lightheadedness, syncope, nausea or vomiting. She reports an increase in caffeine use, in
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cluding the consumption of daily energy drinks and diet coke. The patient also reports starting Flo
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vent inhaler for her asthma, coinciding with the onset of symptoms one month ago. Flovent has b
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een effective in managing her asthma symptoms. She uses Flovent as prescribed, two puffs twice a
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sr day. She denies any cardiac history and reports never having had a cardiac procedure or EKG. T
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he patient reports feelings of anxiety during times of increased stress from work and school also c
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oinciding with her symptoms. sr sr sr

Medications

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Uploaded on: August 8, 2026
Number of pages: 4
Written in: 2026/2027
Type: Exam (elaborations)
Contains: Questions & answers

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