NURS 5603 - Study guides, Class notes & Summaries

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EYoung Cardiovascular SOAP Note Harvey Hoya

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 ...

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 time...

SOAP Note on Harvey Hoya Patient Initials: ____HH___ Age: _57______ Gender:_M_ SUBJECTIVE DATA: Chief Complaint (CC): “I can’t stop snoring when sleeping and I don’t have adequate sleep” History of Present Illness (HPI): the client, HH is a 57-year-old male Hispanic who presented with complaints of challenges sleeping and constantly snoring while asleep. The client is a construction worker and also presented with elevated blood pressure while also indicating that he had intermitt...