The soap notes attached are ok but I need to use it for another student you need to do some changes for look different and it does not have similarity.


Name:  R.G Date: 08/21/2019 Time: 10 AM
  Age: 56 y/o Sex: Female

“I have been experiencing increasing shortness of breath, fatigue and problems sleeping”


R.G, a 56 y/o African American female presents to the office with complaints of
increasing shortness of breath on exertion and mild fatigue for the past five days. The
patient reports that he has been experiencing shortness of breath after climbing stairs or
walking two to three blocks he also reports difficulty sleeping at night and states that he
often need two pillows to feel comfortable. Patient reports that 2 years ago, she suddenly
started experiencing shortness of breath after hurrying for an aeroplane. Following the
incidence, she was admitted to hospital and treated for acute pulmonary edema. After the
pulmonary edema episode, the patient reports that his blood pressure had been high
consistently. Patient denies chills, cough, chest pain, palpitations, vomiting, diarrhea
abdominal pain/distension


Diltiazem 180 mg/d for HTN

Hydrochlorothiazide 50 mg/d for HTN and heart failure

Lopressor 25mg orally BID HTN and heart failure

Glyburide 5 mg/d for diabetes

Indomethacin 25 mg TID for pain


Allergies:  No known Drug allergies


Medication Intolerances: None


Chronic Illnesses/Major traumas: Diastolic dysfunction with diastolic congestive heart
failure, Hypertension (diagnosed 5 years ago), type 2 diabetes mellitus (diagnosed 4 years
ago), arthritis (diagnosed two years ago). Denies a history of asthma  

Hospitalizations/Surgeries: patient was admitted to hospital and treated for acute
pulmonary edema. Patient has no history of surgeries

Family History: Coronary heart disease, hypertension, arthritis ( father), Type 2 diabetes
mellitus ( mother), Hypertension ( older brother), other siblings and her children alive
and well. 

Social History: Patient lives with her husband and youngest son. She works as a teller at
one of the local banks. Patient reports that she takes two glasses of wine after work,
reports a 6-year history of tobacco smoking but states that she quit. Denies use of illicit


Complains of mild fatigue and weakness.
Denies fever chills, night sweats and any
recent unexplained weight loss or gain



Patient reports dyspnea especially when
trying to sleep, which is relieved with
elevation of the head with two pillows.
Patient also reports swelling in lower limbs
and a history of HTN. Denies chest pain,
palpitations, and PND


Denies delayed healing, rashes, skin
discolorations or changes in moles or


Reports exertional dyspnea and wheezing

Name:  S.S Date: 10/10/2019 Time: 12:30 p.m
  Age: 70 Sex: Female
“My skin is turning pale and my feet and hands feel cold”
S.S comes to the clinic with complaints of her skin turning pale and feeling cold in the
feet as well as the hands. The patient explains that she started having these symptoms
three weeks ago. She mentions that the cold feeling in her feet and hands is accompanied
by headache, chest pain, and dizziness, which go away after taking ibuprofen. She also
mentions that she cannot walk for long distances because she feels short of breath and
weak besides feeling exceedingly tired. She often rests to catch a breath. She also notes
that even though she is vegetarian, she has been having an urge to consume dirt. The
patient claims that she had been skipping meals recently since she was diagnosed with
positive H. Pylori. She denies blood in stool, states that the last colonoscopy was in 2005
with normal results.

Medications: Ibuprofen PRN for headache and chest pain 
Levothyroxine 0.50 mcg/daily for hypothyroidism

PMH: Hypothyroidism diagnosed in 2013
Allergies:  NKD
Medication Intolerances: None
She mentions that in 2009, she underwent a breast biopsy for suspected breast cancer, but
the results were negative. Colonoscopy 2005 negative results.
Family History
Father died 20 years ago from coronary artery disease. Mother died 15 years ago from
diabetes. Brother was diagnosed with colon cancer 2 years ago. Other siblings are
Social History
Patient holds a Bachelor’s degree in commerce. Patient worked as a bank manager before
retiring. Patient is married and lives with her husband (74 years of age) and two
grandchildren (19 years and 15 years of age). Patient does not consume alcohol, smoke or
abuse drugs. Patient mentions putting on her seatbelt on always. 
Patient reports feeling extremely fatigued,
dizzy, and feeling weak. Denies, night
sweats, fever, chills, weight change

Patient reports dyspnea and chest pain.
Denies edema 

Patient reports pale skin. Denies bruising,

Patient reports dyspnea and wheezing. Denies

rashes, or lesions  cough, hemoptysis, hx of pneumonia or TB 
Patient wears corrective lenses, reports
blurring vision

Denies abdominal pain, diarrhea, vomiting,
nausea, or changes in stool color or bowel

Denies discharge, hearing loss, ear pain,
ringing in ears

Denies burning, changes in color of urine,
urgency, or frequency or vaginal discharge

Denies nose bleeds or discharge, dental
disease, sinus problems, dysphagia, throat
pain, hoarseness,

Denies joint swelling, back pain, fracture hx,
pain or stiffness, osteoporosis

(Student Name)

Miami Regional University

Date of Encounter:

Preceptor/Clinical Site:

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

Soap Note # ____ Main Diagnosis ______________


Name: O.R

Age: 52

Gender at Birth: Male

Gender Identity: Male


Allergies: Penicillin

Current Medications:


PMH: Hypercholesterolemia,

Immunizations: Updated according to the patient age.

Preventive Care:

Surgical History: None

Family History: Father- alive, 81 years old with coronary artery bypass 5 years ago, HTN

Mother- alive, 78 years old with Diabetes Mellitus, HNT

Social History: Alcoholic beverage social celebrations, ,He is currently a truck driving

Sexual Orientation: Straight

Nutrition History:

Subjective Data:

Chief Complaint: I have severe headache early morning

Symptom analysis/HPI: The patient is a 52-year-old man who complains of symptoms of hypertension, such as severe headache early morning. This patient complained of a worsening of his symptoms one week ago.. He said he recently gained weight because he is truck driving and he is no have time for practice exercise... Blood pressure was measured and increased on 3 different occasions (155/93 mmHg, 145/92 mmHg, 140/90 mmHg, respectively). This confirms that the patient has his own clinical crisis, which in this case is hypertension.

The patient is …

Review of Systems (ROS) (This section is what the patient says, therefore should state Pt denies, or Pt states….. )

CONSTITUTIONAL: Denies loss of consciousness. Denies seizure, tremors. Denies change in vision /blurred vision. Pt states recently gained weight.

NEUROLOGIC: Patient states severe headache early morning. He denies seizures, tremors, loss of consciousness and change in vision /blurred vision.

HEENT: HEAD: Denies any head injury or change in LOC. Eyes: Denies any changes in vision, diplopia or blurred vision. No scleral icterus Ear: Denies pain in the ears. Denies loss of hearing or drainage. Nose: Negative for nosebleed nasal. THROAT: Denies throat or neck pain, hoarseness, difficulty swallowing. Moist mucous membranes. No cervical lymphadenopathy. EARS: Patient denies pain, tinnitus, vertigo, discharge

RESPIRATORY: Patient states shortness of breath. Patient denies cough or hemoptysis. Lungs clear to auscultation bilaterally, no accessory muscle use. Patient denies co


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

“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.

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


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

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 


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


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


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



Denies dyspnea or cough


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 ______________



Age: 74

Gender at Birth:

Gender Identity: Female



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