NR 509 Week 4 SOAP Notes

S: Subjective Information the patient or patient representative told you. Initials: BF Age: 58 years old Gender: Male Height: 5’11” Weight: 197lbs BP: 146/90 HR: 104 Temp: 19 SPO2: 98% Pain (1-10): 0/10 Allergies Medication: Codeine—Nausea and vomiting Food: No Known Food Allergies Environment: No Known Environmental Allergies History of Present Illness (HPI) CC is a BRIEF statement identifying why the patient is here - in the patient’s own words - for instance "headache", NOT "bad headache for 3 days”. Sometimes a patient has more than one complaint. For example: If the patient presents with cough and sore throat, identify which is the CC and which may be an associated symptom Chief Complaint (CC): Chest Pain/Tightness Onset: 1 month Location: Center of my chest” Duration: “It lasts 2-3 minutes when it happens” Characteristics: “Intermittent tightness and discomfort” Aggravating Factors: Activity, yard work, climbing stairs Relieving Factors: Rest Treatment: No medication treatments, seeking medical treatment today Current Medications Medication Dosage Frequency Length of Time Used Reason for Use Metoprolol 100mg Daily 1 year Hypertension Atorvastatin 20mg Daily at bedtime 1 year High cholesterol Omega 3 Fish Oil 1200mg Twice Daily 1 year High cholesterol Past Medical History (PMHx) – Includes but not limited to immunization status (note date of last tetanus for all adults), past major illnesses, hospitali