Rafael Camejo
Soap Note # Main Diagnosis ( Exp: H&P Note #3 DX: Hypertension)
Student Name
Miami Regional University
Date of Encounter:
Preceptor/Clinical Site:
Clinical Instructor: Dr. Rafael Camejo
Soap Note # Main Diagnosis ( Exp: Soap Note #3 DX: Hypertension)
PATIENT INFORMATION
Name: Mr. DT
Age: 68-year-old
Gender at Birth: Male
Gender Identity: Male
Source: Patient
Allergies: PCN, Iodine
Current Medications:
· Atorvastatin tab 20 mg, 1-tab PO at bedtime
· ASA 81mg po daily
· Multi-Vitamin Centrum Silver
PMH: Hypercholesterolemia
Immunizations: Influenza last 2018-year, tetanus, and hepatitis A and B 4 years ago.
Preventive Care: Coloscopy 5 years ago (Negative)
Surgical History: Appendectomy 47 years ago.
Family History: Father- died 81 does not report information
Mother-alive, 88 years old, Diabetes Mellitus, HTN
Daughter-alive, 34 years old, healthy
Social History: No smoking history or illicit drug use, occasional alcoholic beverage consumption on social celebrations. Retired, widow, he lives alone.
Sexual Orientation: Straight
Nutrition History: Diets off and on, Does not each seafood
Subjective Data:
Chief Complaint: “headaches” that started two weeks ago
Symptom analysis/HPI:
The patient is 65 years old male who complaining of episodes of headaches and on 3 different occasions blood pressure was measured, which was high (159/100, 158/98 and 160/100 respectively). Patient noticed the problem started two weeks ago and sometimes it is accompanied by dizziness. He states that he has been under stress in his workplace for the last month. Patient denies chest pain, palpitation, shortness of breath, nausea or vomiting.
Review of Systems (ROS)
CONSTITUTIONAL: Denies fever or chills. Denies weakness or weight loss. NEUROLOGIC: Headache and dizziness as describe above. Denies changes in LOC. Denies history of tremors or seizures.
HEENT: HEAD: Denies any head injury, or change in LOC. Eyes: Denies any changes in vision, diplopia or blurred vision. Ear: Denies pain in the ears. Denies loss of hearing or drainage. Nose: Denies nasal drainage, congestion. THROAT: Denies throat or neck pain, hoarseness, difficulty swallowing.
RESPIRATORY: Patient denies shortness of breath, cough or hemoptysis.
