EYoung Cardiovascular SOAP Note Harvey Hoya

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.”