Aileen Alvarez 2/7/2023 PAC-Lab SOAP for Chana Kumar Student Name: Aileen Alvarez, PA-S Patient Name: Chana Kumar Date of Service: 2/7/2023 Age/DOB 86-yr-old (XX-XX-XXXX) Sex Female
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Aileen Alvarez 2/7/2023 PAC-Lab SOAP
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Aileen Alvarez 2/7/2023 PAC-Lab SOAP
Aileen Alvarez
2/7/2023
PAC-Lab
SOAP for Chana Kumar
Student Name: Aileen Alvarez, PA-S
Patient Name: Chana Kumar
Date of Service: 2/7/2023
Age/DOB 86-yr-old (XX-XX-XXXX)
Sex Female
Use of Interpreter: None
Reliability Patient; Good historian
SUBJECTIVE
*Chief Complaint: Fatigue that ha...
Aileen Alvarez
2/7/2023
PAC-Lab
SOAP for Chana Kumar
Student Name: Aileen Alvarez, PA-S
Patient Name: Chana Kumar
Date of Service: 2/7/2023
Age/DOB 86-yr-old (XX-XX-XXXX)
Sex Female
Use of Interpreter: None
Reliability Patient; Good historian
SUBJECTIVE
*Chief Complaint: Fatigue that has not been resolved only escalated for the last 2 months.
HPI: Mrs.Kumar is an 86-year-old Indian female patient who is presenting to the clinic because
of acute shortness of breath during physical activities and fatigue that has exceeded for 2 months.
She recently experienced palpitations during her first water aerobics class. A checkup was done
on her heart rate, and it was at 120 beats per minute but subsided after 30 minutes. She is feeling
normal in the morning portions of the days but gets tired as the day progresses. However, has
currently denied having any difficulty managing her typical activities during her daily routine.
Mrs. Kumar is normally healthy but has been dealing in her own way with chronic constipation;
has not been on any recent trips or been exposed to sick people.
Past Medical History:
Hypertension
-Takes metoprolol prescribed by provider.
Coronary Artery Bypass Graft (8 years ago)
Coronary Artery Disease (8 years ago)
-Takes aspirin as prescribed by provider.
Gastroesophageal Reflux Disease
-Takes esomeprazole for her reflux as prescribed by provider.
Hyperlipidemia
-Takes atorvastatin as prescribed by provider.
Osteoarthritis
This study source was downloaded by 100000865194348 from CourseHero.com on 04-24-2023 13:36:30 GMT -05:00
, -Takes ibuprofen per need if pain radiates beyond comfort per provider prescription.
G4P4: Gravidity and Parity
Medications:
HTN= Metoprolol 100 mg, PO, 1 daily, Active
CAD=Aspirin 81 mg, PO, 1 daily, Active
HLD= Atorvastatin 20 mg, PO, 1 daily, Active
OA= Ibuprofen 600 mg, PRN, PO, Active
GERD= Esomeprazole 40 mg, PO, 1 daily, Active
OTC Bowel medications, Active
Allergies: NKDA
Social History: No tobacco being used, only having one glass of wine when special occasions
arise.
Sexual History: Was not asked on this visit, but the patient has been a widow for the last 20
years.
Family History:
Mother deceased at 76 because of stroke.
Father deceased at 78 from a myocardial infarction.
Siblings: None
Grandparents: Unknown history for both sides.
Children: Three living adult children; one deceased due to an accident.
OBJECTIVE
Physical Examination:
Height: 5'2 Weight: 122 lbs. BMI: 22.3
Vitals: Temp: 98.2 F, HR: 110 BPM, BP: 138/92 mmHg (normotensive/lying down/L side), RR:
16 Unlabored, O2: 95% RA
General Survey: Alert and orientated x 4, in no acute distress per my visual aspect of her.
HEENT & Neck: Normocephalic pupils had a PERRLA, trachea midline, conjunctival rim
pallor, but no JVD.
Cardiovascular: Her heart rate was at 110, also heard a murmur which could hint at early systolic
signs.
This study source was downloaded by 100000865194348 from CourseHero.com on 04-24-2023 13:36:30 GMT -05:00
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