Soap note

SOAP NOTE

Name:  G.P Date: 08/30/2019 Time: 1500
  Age: 65 Sex: M
SUBJECTIVE
CC: 

“Increased leg pain with walking and other exercises” 

HPI:  G.P, a 65 y/o Caucasian male presents to the clinic with complaints of increasing
leg pain with walking and other exercises. Patient reports that the pain started 2 years ago
and over the past few weeks it has become more severe. He states that the pain in his
calves starts/gets worse after walking around 200 yards and is relieved with rest. The pain
resolves within 10 minutes of rest. As a consequence, patient reports that he has become
less physically active. Patient denies rest pain. He states that the pain is worse on his right
calf compared to his left calf. Patient reports that he was diagnosed with type 2 diabetes
mellitus ten years ago which he manages using daily Metformin. He also has stable
angina, for which he takes atenolol in addition to occasional nitroglycerin. Patient denies
numbness, burning sensation, or reduced feeling in lower extremities, leg ulcers,
blackening over toes, thickening of toenails, swelling, discoloration along superficial
veins, and skin discoloration.
Medications:

Metformin 500 mg bid for type 2 diabetes mellitus

Atenolol 100 mg PO daily for Angina pectoris

Nitroglycerin 2.5 mg PO q6-8hr for Angina pectoris

PMH

Allergies:  No known drug or food allergies

Medication Intolerances: None

Chronic Illnesses/Major traumas: Type 2 diabetes mellitus (diagnosed ten years ago),
Stable angina diagnosed 3 years ago, atherosclerosis (diagnosed 5 years ago)

Hospitalizations/Surgeries: Patient was hospitalized for 3 days because of chest pain 3
years ago. No history of surgeries 

Family History

Father had peripheral vascular disease, type 2 diabetes mellitus, HTN, died from a stroke
at the age of 82. Mother had HTN and colon cancer, died at the age of 85. Brother had
PAD.

 
Social History

Patient is married and has two sons. Lives with wife and youngest son. He is a retired
mechanical engineer, currently operates car workshop/garage. Reports drinking alcohol
(1-2 beers per week). Reports smoking history (7 cigarettes per day for the past 40 years).
Reports that he tried to quit smoking after developing angina but “After nearly 30 years
of smoking, I think it’s not possible”. Denies illicit drug use 

ROS
General

Denies recent weight change/loss, fever,
chills or weakness  

Cardiovascular

Denies chest pain, dyspnea on exertion,
orthopnea, PND, or edema

Skin

Denies delayed healing, rashes, pallor,
Shiny/scaly skin or any skin discolorations

Respiratory

Denies dyspnea or cough

Eyes

Reports that he is short-sighted and uses
corrective lenses. Denies blurring, or
visual changes

(Student Name)

Miami Regional University

Date of Encounter:

Preceptor/Clinical Site:

Clinical Instructor: Patricio Bidart MSN, APRN, FNP-C

Soap Note # ____ Main Diagnosis ______________

PATIENT INFORMATION

Name:L.G

Age: 74

Gender at Birth:

Gender Identity: Female

Source:

Allergies:

Current Medications:

1-Aspirin 81 mg daily.

2-Lisinopril 20 mg daily

3- atorvastatin 20 mg daily,

4-fluticasone propionate/Salmeterol 250/50 inhaler 1 puff twice a day

5-ipratropium bromide/albuterol, inhaled 0.5 mg/2.5 mg/3 mL nebulizer every 6 hours as needed;

6- levalbuterol, inhaled 0.63 mg/3 mL nebulizer every 8 hours as needed.

Denies the use of herbal supplements.

PMH: Patient had significant medical history for COPD,HTN, Hearing loss

Allergies: NKDA.     

Immunizations: Childhood immunizations are up to date.

Preventive Care:

Surgical History:

Family History:

Mother: 94 years old, Alive – Anxiety, GERD, CAD, Asthma

Father: Deceased – coronary artery disease (CAD) < 55 years,

Brother: Alive – HTN, DM type II, COPD (76 years old)

Son: Alive – no known health concerns (50 years old).

Social History: Currently married with one child who lives with them, they live in a single home that owned She is Christian. She every day works in the garden early in the morning, but lately is difficult to this due to increases the shortness of breath. Admitted that she smokes and she tries to cut but it is difficult, but she is the thing to quit (no guns in the home, no lead exposure)

Sexual Orientation:

Nutrition History:

Subjective Data:

Chief Complaint: “Shortness of breath.”

Symptom analysis/HPI:

The patient is … is a 74-year-old female who presents today to the clinic, complaint worsening of the shortness of breath, wheezing and increases productive cough with no changes in the sputum color. She has experiences with dyspnea in exertion, she did not report fever, night sweet or chest pain or palpitation. She had had a history of chronic obstructive pulmonary disease (COPD) exacerbation twice last year, hypertension (HTN), and cardiac Cath about 3 years ago. She had a 40 pack-year smoking history but did not report using alcohol or illicit drug. Her medication, low dose daily (81mg) aspirin (ASA), Lisinopril 20 mg daily, atorvastatin 20 mg daily, fluticasone propionate/Salmeterol 250/50 inhaler 1 puff twice a day tiotropium inhaler 18 mcg 1 cap daily, ipra