SOAP notes Literature & Language Research Paper Essay (Other (Not Listed) Sample)
Develop SOAP notes with 5 differential diagnosis
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SOAP Notes
Student’s Name
Institutional Affiliation
Patient Information
Name: Mr. Hendrick
Age: 67 years
Sex: male
Race: white
SOAP Notes
S
Chief complain- feelings of tiredness and shortness of breath that has lasted for a few days.
HPI- Mr. Hendrick a 67 years old white male has reported to the ER with history of tiredness and shortness of breath that worsens with walking.
Current medications: He used Tylenol for a suspected fever the previous night.
Allergies- Mr. Hendrick has no known drug or food allergies.
PMHX- Mr. Hendrick has no surgical history and has never undergone a blood transfusion. He has a two incidents history of hospital admissions. The first in 2009 following a diagnosis of pneumonia and the second incident in 2016 following a road accident that left him with a fracture of the left arm and tissue injury.
Social Hx- Mr. AB is a retired teacher in a local high school. He lives with his wife and their last-born daughter. Currently, he is doing small scale farming on his farm. He has a history of tobacco smoking. However, he is trying to quit smoking. Currently, he smokes three sticks of cigarettes per day. He uses alcohol occasionally.
Family Hx- Mr. AB’s mother was asthmatic and his grandfather was diabetic (paternal). There are no other chronic illnesses in the family.
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