SOAP NOTE

Date: 10/26/2016

Time:

Source:

Reliability:

Examiner:

Service:

Demographics: (sentence format)

E.B. Aug. 2 1963, 53yo Male, born and raise in St. Kitts. Single.

Work as a landscaper for the government and sale meat on the weekend.

No religion

Subjective:

CC:

“I had a vehicle accident”

H.P.I

-Patient stated he was experiencing headache when he got hit by a car, and his car end up hitting a pole.

-Hit head and shoulder

-wasn’t wearing seatguy.

-transported to the emergency room by an emergency

PMH:

Medical

1. Childhood illnesses

Mumps, Wheeze before and still now, Up to date with immunization

2. Adult illnesses, including JAMTHREADS

-High blood pressure, was taking Panadol and Capoten (but patient was not compliant).

-Was on blood thinning

(NOTES: PLEASE USE THE INFORMATION TO GET DRUGS NAMES AND MORE PAST MEDICAL DETAILS)

-Stated he stopped smoking and drinking 2 years ago, and did remember when he started.

Medications given: at 2:40pm when her was admistered: Capoten 25mg

Nacl 0.9%

Panadol

Dezide 25 mg

-8/11/2016:

patiented admitted for Shortness of breathe and epigastric pain.

History of Hiatal Hernia

-Congested heart, and Hypertension

-pitting edema in both les

Medications given: Tramedol 50 mg

Amlodipinol

Nexium-20mg

EGK- mildl dilated heart

OB/GYN

Psychiatric:

Patient appeared to be depressed due to his family issues. Stated that he had a psychiatric elevation during his hospital stay.

(please refer to chart to make sure)

Surgical:

Past surgery done on his feet, due remove abscess. (PLEASE REFER TO CHART for more info)

Health Care Maintenance

( reefer to chart)

Current meds

Please use the charts to find out the names.

Allergies

No known allergies

Family Hx:

-Father had kidney problems and passed away from prostate cancer

-Mother had diabetes and passed away during her state in the US.

Older sister currently living in the US, had a heart surgery, patient didn’t know the cause.

Have 4 children, 27yo boy, 24 yo girl, 23 yo girl, 12 yo girl. From different women, and not sure if they are healthy are not.

Social Hx:

Diet consist of a varieties, and examples given were: pizza, eggs,, tea. Pretty much anything.

Only exercise he does, was for walk for work, garndening and saling mean. Examepls giving: walking to and from car.

-traveled to Caanda 3 years ago and stayed for 6 months. Also recently traveled to Cuba.

Liver with his girlfriend.

ROS:

Constitutional :

-loss of appetite, forgetting things, and hard time remembering names. Patient did know remember when he had for dinner during the interview.

-getting fatigue, tired, fever, dizzy. Vertigo,

-Patient is obese

Heavy beathing

Integument :

A Bruise was noted on the spot where he had the blood thinning injection when he admitted to the hospital.

Head/ Eyes/ Ears : / Nose:/ Throat:

- Frequent headacehes, comes and go

-vision is getting worse, look specks and spots after accident

Neck:

Pain comes and go on the left side and a bit swollen.

Dry mouth, sore throat, hoarseness, and sometimes hard to shout.

Resp :

Shortness of breath, wheeze (since before the accidenct)

Breast :

Testicular :

CV :

High blood pressure, dilated cardiomyopathy

Shortness of breath

GI :

-dysphasia, loss petite recently, constipation

GU :

Frequent, and concentrated, dark yellow in color.

Endocrine :

Musculoskeletal :

Neuro :

-had blackouts before accicent.

-memory getting worse,

-numbness and tingling in left hand,

Psychiatric:

-depression and tension, memory changes

Peripheral vascular:

Objective:

PHYSICAL EXAM:

General:

VS: Temp—

Pulse— 96 bPM

Resp— 20

BP— 160/100

Weight—

Height--

BMI---

Skin:

HEENT:

Lymph:

Neck:

Back:

Lungs:

CV:

Abdomen:

Extremities:

Genital Exam:

Rectal:

Musculoskeletal:

Neuro:

Labs/tests:

ASSESSMENT/PLAN :

Summary:

Problem List:

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4.

1. __________________________

DIffernetial diagnosis:

1..Nerve compression

2. Hypoxemia, secondary to Congenital cardiac (chest pain, neck pain, motor accident, obesity

3. possible cord injury (due to concussion, numbness and tingling)

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Plan:

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4.

2. __________________________

DIffernetial diagnosis:

1.

2.

3.

Plan:

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2.

3.

4.

3. ___________________________

DIffernetial diagnosis:

1.

2.

3.

Plan:

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2.

3.

Your name here: _______________________________

2nd Year Medical Student