Episodic/Focused SOAP Note

Patient Information:

• Name: MH
• Age: 68
• Gender: Male
• Race: White American

Subjective:

• Chief Complaint (CC): “Shortness of breath.”
• History of Present Illness (HPI): The patient is a 68-year-old White American male presenting with a complaint of shortness of breath. The shortness of breath is described as constant and worsening at night. It is accompanied by a persistent cough that continues throughout the night. The patient also reports swelling in the abdomen and legs, and a recent weight gain of five pounds. He mentions being prescribed a “fluid pill” (diuretic) for the swelling.
• Current Medications:
  • The patient reports not taking any medications currently.
• Allergies:
  • No known drug, food, or environmental allergies.
• Past Medical History (PMHx):
  • The patient has a positive medical history, though specific conditions are not detailed in this note.
• Social History (Soc Hx):
  • The patient denies any use of tobacco or alcohol. He has been married for 43 years.
• Family History (Fam Hx):
  • Father passed away at age 80 from a heart attack.
  • Mother passed away at age 75 from severe chest pain, possibly related to cardiovascular disease.
  • No additional family history of cardiovascular illnesses was reported.

Objective:

• Review of Systems (ROS):
  • General: Reports a five-pound weight gain.
  • HEENT: No rhonchi or wheezes.
  • Skin: Cool and dry skin.
  • Cardiovascular: No chest pain or chest discomfort. Positive for peripheral edema.
  • Respiratory: Persistent cough with clear phlegm.

Assessment:

• Shortness of breath: The patient’s symptoms of shortness of breath, especially worsening at night, along with a persistent cough and peripheral edema, are concerning for a possible underlying cardiovascular or pulmonary condition. The recent weight gain and edema suggest fluid retention, potentially indicative of heart failure or another condition requiring further evaluation.

Plan:

1. Further Diagnostic Testing:
   • Order a chest X-ray to assess for any pulmonary congestion or other abnormalities.
   • Obtain an echocardiogram to evaluate heart function and rule out heart failure.
   • Perform blood tests, including BNP (B-type natriuretic peptide), to assess for heart failure, and basic metabolic panel (BMP) to evaluate kidney function and electrolyte levels.
   • Consider a pulmonary function test (PFT) if obstructive or restrictive lung disease is suspected.
2. Medication Management:
   • Review and potentially restart or adjust diuretic therapy to manage fluid retention, pending test results.
   • Consider adding an ACE inhibitor or beta-blocker if heart failure is confirmed.
3. Lifestyle and Education:
   • Educate the patient on the importance of monitoring daily weight and reporting any rapid increases, which may indicate worsening fluid retention.
   • Advise on dietary modifications, such as reducing sodium intake, to help manage fluid retention.
4. Follow-up:
   • Schedule a follow-up appointment in one week to review test results and adjust the treatment plan as necessary.
   • Encourage the patient to seek immediate care if symptoms worsen, especially if there is increased shortness of breath, chest pain, or further significant weight gain.

Note: Documentation and management will be updated based on the results of the diagnostic tests and the patient’s response to initial interventions.