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Comprehensive SOAP TemplateNURS 6512 N-6 Week 6 Review Case 1This template is for a full history and physical. For this course include only areas that are related to the case.Patient Initials: RH____Age: 60_____Gender: _M______SUBJECTIVE DATA: Chief Complaint (CC): “I am having shortness of breath and not feeling so good”History of Present Illness (HPI): 60-year-old Caucasian male presents to the office today experiencing shortness of breath and not feeling well for past four days. Cardiac history is positive for a myocardial infarction three years ago, followed by a 3-vessel coronary artery bypass surgery, hypertension, and CHF. The patient has been asymptomatic since surgery with no c/o chest pain. Two weeks ago, he was unable to complete his daily one mile walk at the high school track. Over the last four days he has experienced shortness of breath walking from room to room, and even at rest. He has noticed swelling in his abdomen and legs. He has been sleeping in a recliner past four nights and states he is unable to lay flat in bed. Yesterday he noticed increased shortness of breath when talking. He claims nothing seems to make it better and that he has been ona fluid pill in the past but ran out three weeks ago, and didn’t get it refilled because it keeps him up all night going to the bathroom. Denies chest pain, pressure or tightness. Positive for cough, expectorating clear phlegm. States he has gained five pounds this week, and reports symptoms to be a 10/10. Medications: Lasix 80 mg by mouth daily (hasn’t taken for three weeks)Plavix 75 mg by mouth once dailyMetoprolol 100 mg by mouth twice dailyLipitor 80 mg by mouth once daily Nitroglycerin 0.3 mg sublingual every 5 minutes as needed, up to 3 doses in 15 minutesAllergies: Aspirin- hives and swelling of lips and tonguePast Medical History (PMH): MI in 2014CHF in 2013Hypertension 2012Chicken pox as a child
Past Surgical History (PSH): CABG 3-vessel 2014Right inguinal hernia repair in 2000Sexual/Reproductive History: Sexually active with wife of 40 years. Denies history of STDs/STIs. States has occasional erectile dysfunction since heart surgeryPersonal/Social History: 30 pack/year smoking history. States he has cut down to 3 cigarettes/day. Denies ETOH or illicit drug use. Walks one mile daily until 2 weeks ago, prior to visit. Retired from General Electric five years ago. States he is on a heart healthy diet and is compliant. Normally is able to perform ADLs but has a hard time for past two weeks due to increased SOB. In his spare time, he likes to do woodworking in his garageImmunization History: Flu and Pneumonia vaccine 2016Tdap vaccine in 2013Zostavax vaccine in 2016Significant Family History:Father died at 60- sudden death of unknown cause,mother alive and well at 80 with osteoarthritis, sister died at 46 with AMI, has a son who is alive with no significant health history, and a daughter age 44 with history of hypertensionLifestyle: Heterosexual male married 40 years living in a rural subdivision. Low crime rate. Retired from a factory job five years ago. Receives a monthly