SOAP Note

Name: NS
Date of Birth: xx/xx/1950
Age: 74 yo
Gender: Male
Occupation: Retired professor (Geology and Civil Engineering).
Marital Status: Married

CC: “I have not been feeling up to par lately; perhaps all together for two to three months now. I
am fatigued and I have no physical energy”.

SN is a 74-year-old male with a past medical history of hypertension, coronary artery disease,
benign prostatic hyperplasia, hyperlipidemia and neck arthritis who presents with progressive
fatigue and shortness of breath. His fatigue began approximately 3 months ago and is described
as constant, generalized low energy that persists throughout the day. It is present most of the time
and does not fluctuate with time of day. The patient did not specify severity in numerical terms
but said that it significantly interferes with daily functioning, as he reports being unable to
complete household chores or “do any work.”, He also noted that the fatigue worsens with
exertion or routine activities and improves somewhat with rest and sitting still. His shortness of
breath began 1–2 months ago and has gradually worsened, now occurring with minimal exertion
such as walking short distances or climbing even a single flight of stairs, and at times present
even at rest. He describes it as an “inability to catch my breath,” stating he feels “whooped on the
flat after a short block.” The dyspnea is aggravated by exertion, occasionally wakes him from
sleep at night, and is relieved with rest. Severity was not stated in numerical value but per his
description it is high, as he becomes breathless after only ~10 steps or climbing stairs. He
attributes an occasional dry cough that is worse when lying down, to a recent cold 3 weeks ago;
however, the cough and dyspnea have persisted beyond the infection. He also reports difficulty
staying asleep due to shortness of breath and notes a decline in his activity tolerance and overall
functional capacity. His activities of daily living are significantly affected by his symptoms, but
he has not sought prior medical evaluation or tried treatment for fatigue or dyspnea. As stated
above he has a history of coronary artery disease diagnosed several years ago during an
evaluation for chest pain but has not required intervention. He reports no recent anginal
symptoms, describing only occasional mid-chest pressure without radiation. The patient
discontinued the blood pressure medication about 5 to 6 weeks ago without improvement in
symptoms and is only taking daily multivitamins. The patient denies chest pain, palpitations,
hemoptysis, discomfort radiating to the arm or jaw, fever, weight loss, and night sweats.
PAST MEDICAL HISTORY

Adult illnesses: Hypertension for 6–7 years (stopped medication 5–6 weeks ago), Coronary
artery disease with rare chest pressure, Cervical arthritis (“wear and tear”), Benign prostatic
hyperplasia (stable, mild), and Hyperlipidemia (diet controlled).
Childhood illnesses: Typical coughs/colds, no significant illness.
Surgical Hx: None reported.
Hospitalizations: Denies.
Accidents/Injuries: Remote fractures (forearm, lower leg in youth). Pt stated, “I broke the
smaller of the two bones in my right lower leg playing soccer when I was a teen, and on a
separate occasion I broke my forearm playing football”.
OB/GYN, LMP: Not applicable.
Psychiatric Hx: Denies depression, mood changes, memory loss, hallucinations.
Medications: Prescribed medication: stopped antihypertensive medication 5-6 weeks ago stating
it was causing excessive urination.
OTC: Daily multivitamin (wife insists) Herbal: None Compliance: Poor self-discontinued
prescribed medication without medical advice.
Health Maintenance: Patient cannot remember last routine physical. EKG: Done previously
during evaluation of chest pain (when CAD was diagnosed). No information given for
Colonoscopy or annual lab work.
Immunizations: Up to date with Flu, Covid 19, Hep B, Pneumonia, Tdap, and Zoster
Allergies: No known food, drug or environmental allergies.

FAMILY MEDICAL HISTORY:

Grandparents (maternal and paternal): history unknown
Parents: Father died at age 83 of pneumonia; mother died at age 89 following a stroke. Both
were otherwise healthy throughout life.
Siblings: no information given
Familial Disease: none reported
Communicable Diseases: Denies
Children: Two adult sons, alive and well, no known medical problems.
Genetic/hereditary disease: Patient denies knowledge of any genetic conditions in the family.
Other: No family history of early cardiac disease or malignancy noted.
Travel: Patient denies recent travel; no exposures to endemic infections.
SOCIAL HISTORY
Occupation: Retired professor (Geology and Civil Engineering).
Living situation: Resides at home with his wife.
Marital status: Married 35 years, supportive spouse.
Diet/Exercise: Wife cooks healthy meals due to his HTN; enjoys steak occasionally. Walks daily
when able.
Caffeine: Denies regular intake.
Smoking: Former smoker for 25 years, up to 1.5 packs/day. Quit 29 years ago (≈38 pack-years).
Drug use: Denies illicit drug use.
Alcohol use: Drinks 1 glass of wine with dinner and 1 shot of scotch before bed (daily). CAGE
score is 0.
Cultural/Spiritual practices: Denies practicing a religion or spiritual involvement.
Sexual history: Private; denies STIs.
Stressor/Abuse: No history of abuse reported; primary stressor is declining health/limited
ADLs.
Barriers to care/Economic status: Has medical insurance, reports affordability of clinic co-
pays and medications; no barriers to care.
Safety measures: uses seatbelt when driving
Social/Spiritual practices: Denies
Review of Systems
 Constitutional: Pt accepts fatigue, decreased appetite, recent 15-lbs weight gain but
denies fever and chills
 Skin: Pt accepts seborrheic keratoses but denies changing moles, pruritic lesions or rashes
 Head: Denies headaches, trauma, or loss of consciousness
 Eyes: Denies photophobia, vision loss or diplopia
 Ears: Denies pain, hearing loss, and otorrhea
 Nose: Denies post-nasal drip, sinus pressure, nasal congestion, bleeding, trouble
breathing through the nose.
 Throat: Denies sore throats, difficulty swallowing, or throat pain.
 Neck: Accepts having neck arthritis, denies swollen lymph nodes, and limited range of
motion.
  Respiratory: Accepts having exertional dyspnea, orthopnea, paroxysmal nocturnal
dyspnea and dry cough. Denies wheezing and coughing up sputum.
 Cardiovascular: Accepts occasional palpitations, peripheral edema, history of
CAD/angina, hypertension. Denies chest pain, irregular heartbeats, atrial fibrillation and
tachycardia.
 Peripheral Vascular: Accepts peripheral edema. Denies varicose veins, spasms in the calf,
cold extremities, claudication, color changes.
 Breast: Denies swelling, skin changes around the nipple, discoloration and pain.
 Gastrointestinal (GI): Denies abdominal pain, difficulty defecating, abdominal bloating,
and blood in stool.
 Urinary: Accepts nocturia and weak urinary stream (BPH) but denies urinary leaking and
pain with urination.
 Genital: denies testicular pain/swelling, erectile dysfunction, or history of STIs.
 Musculoskeletal: Accepts neck arthritis pain and stiffness. Denies fractures, muscle
weakness, muscle atrophy.
 Neurological: Denies decreased sense of smell, upper and lower extremities numbness,
tingling, and denies seizures.
 Psychiatric: Denies sadness, depression, lack of interest, memory loss, or hallucinations.
 Endocrine: Denies heat/cold intolerance, sweating, or hair changes.
 Hematologic: Denies easy bruising, bleeding, or anemia.

OBJECTIVE
Physical Exam:

Height: 5’8’’; 68 in (173 cm) Weight: 160 lb (74.5 kg) BMI: 25.0 (normal)
Cognitive status: Alert and oriented ×4

Vital Signs
Temperature: 36.8 °C (98.2 °F), oral
Pulse Rate: 104 bpm, regular rhythm, weak strength
Blood Pressure: Left arm: 154/90 mmHg; Right arm: 160/94 mmHg → Hypertensive, normal
pulse pressure
SpCO is 3%
Respiratory Rate: 24 breaths/min, regular, unlabored
SpO₂: 91% on room air (low)
General survey: The patient is alert and oriented ×4, cooperative, and provides a reliable
history. He is a well-developed, well-nourished 74-year-old male who ambulates independently
with normal posture. He is not in acute cardiac distress but demonstrates mild respiratory distress
with exertion. He appears comfortable at rest during the encounter. Mood and affect are
appropriate, with no signs of depression; however, he expresses frustration about fatigue and
shortness of breath limiting his daily activities. He communicates clearly and demonstrates good
understanding of his condition.
Skin: Seborrheic keratoses present. Skin cool to touch. No jaundice, spider angiomas, palmar
erythema, lesions, discoloration, or varicose veins. Good skin mobility and turgor.
Hair: Normal distribution and texture. No hair loss noted.
Nails: Nails appear healthy with no ridging, pitting, or peeling. Nailbeds are normal with
capillary refill is 2 seconds on fingers and toes.
HEENT: Eyelid exam shows no ptosis, erythema, or swelling. The conjuctivae is pink with no
discharge, the sclerae is anicteric, and there is no edema or redness around the orbital area.
Ear: External ears normal with no deformities, lesions, or erythema. Visual acuity with Snellen
pocket card: OD 20/20, OS 20/20. Fundoscopy exam shows reflex bilaterally and optic disc is
sharp. Ear canals clear; tympanic membranes pearly gray, translucent, intact with normal cone of
light. No edema, perforation, exudate, or hearing deficit. Normal Weber and Rinne test. Nose: No
lesions, discharge, or bleeding are noted. Sense of smell intact. Sinuses: No tenderness over
frontal or maxillary sinuses on palpation or percussion. Throat: Tonsils without exudate,
oropharynx is not injected, clear mucosa. Uvula midline. No oral ulcers, vesicles, periodontal
erythema, or bleeding. Tongue is pink, non-tender, with no masses. Soft palate elevates
symmetrically. Speech phonation and articulation are appropriate. Patient able to chew and grind,
masseter and temporal muscles with appropriate tone and bulk.
Neck: Elevated JVP and positive HJR. Filling level of jugular veins measured at 5-6 cm
bilaterally and there is positive hepatojugular reflux. No neck swelling, lesions or scars. Thyroid
gland non-tender, without enlargement or nodules. Trachea midline and mobile. Thyroid and
cricoid cartilages, as well as the isthmus, are appreciated without abnormality.
Breast: No gynecomastia, nipple discharge, changes in the anatomy.
Thorax and Lungs: Orthopnea, PND, dry cough, bilaterally diminished breath sounds in lower
lung fields, fine crackles (rales). Thoracic expansion is symmetric bilaterally. Normally A-P
diameter. There is no accessory muscle use. Tactile fremitus is increased over lower 1/3 of lung
fields posteriorly R>L. Bilateral dullness to percussion of lower one third to one half of posterior
thorax R>L. Breath sounds are diminished in the lower one-third to one-half of lung fields
bilaterally, with fine crackles present. No egophony, bronchophony, or whispered pectoriloquy
noted.
Cardiac: Tachycardic, hypertensive, PMI is palpated 2cm lateral to midclavicular line within the
6th intercostal space- laterally displaced PMI, S3/S4 gallop. No significant change while
standing, squatting, during Valsalva maneuver, or with sustained handgrip.
Abdomen: Palpable liver edge at 1 cm below right costal margin, normoactive bowel sounds
present, no tenderness and no splenomegaly. Soft non distended abdomen throughout all
quadrants and no herniation.
PVS: Peripheral edema (1-2+ pitting to upper shin), diminished pulses, swollen ankles
bilaterally. Ankle brachial pressure index (ABI) is normal 1.0-1.4 ratio of ankle to brachial BP.
MSK: Arthritis in neck. Normal bulk and tone and no asymmetrical deformity of the back. No
tenderness or spasm of the paraspinal muscles. No localized tenderness of the spinous processes
of pelvic structures. Negative knee drawer test. Normal and equal bilateral ROM and stability.
Neuro: Alert and oriented ×4, no deficits noted, normal sensory test, light touch, pain,
temperature, vibration, and proprioception are grossly intact. Normal eye fixation with rapid
head movement. Cranial nerves I-XII intact. Mini-mental state exam (MMSE) is 3/3 registration
and recall. Attention is intact, names 2/2 objects accurately, able to follow multi-step commands.
Spatial and executive function is intact on drawing task. MMSE score is 30.
GU: Mildly enlarged prostate. No nodules and normal shape and consistency of prostate. Normal
external genitalia, no masses or tenderness, and no urethral discharge.
Rectal exam: Normal sphincter tone, no masses or tenderness. Guaiac negative.

Assessment and Plan of Care

Labs/Studies ordered: CBC w/ Diff, BNP, 12 lead EKG, Chest x-ray PA and Lateral, Lipid
Panel, CMP and Urinalysis
ECG (order date 09/09/2025 at 8 am): Pending. Ordered to check the rhythm, ischemia,
hypertrophy.
Chest X-ray PA/Lateral (order date 09/09/2025 at 8 am): Ordered to assess cardiomegaly,
pulmonary congestion, effusions.
CBC (order date 09/09/2025 at 8 am): Ordered to rule out anemia or infection.
CMP (order date 09/09/2025 at 8am ): Ordered to assess electrolytes, renal, hepatic function.
Lipid Panel (order date 09/09/2025 at 8 am): Ordered for CAD risk and hyperlipidemia
monitoring.
BNP (order date 09/09/2025 at 8 am, result pending): Elevated BNP will support the diagnosis
of CHF.
Lab results: Result finalized at 9:00 am on 09/09/25:
EKG: interpreted on 09/09/2025 at 9 am
Interpretation: normal sinus rhythm with evidence of left ventricular hypertrophy and
repolarization abnormality, along with a prolonged QT interval. These findings are consistent
with chronic hypertension and structural heart disease, supporting a diagnosis of CHF and CAD.

BNP:

630 µg/L, which is well above the normal

range (<3.1 µg/L). A BNP greater than 600 pg/mL is strongly suggestive of moderate congestive heart failure,
matching his symptoms of dyspnea, orthopnea, PND, edema, and weight gain.

CBC: within normal limits, with no evidence of anemia, leukocytosis, or thrombocytopenia. This supports that the
patient’s fatigue and dyspnea are not due to a hematologic cause but more consistent with cardiac pathology (CHF).

CMP: largely within normal limits, except for elevated BUN (30 mg/dL) with normal creatinine, consistent with
possible prerenal azotemia in the setting of CHF. Electrolytes, liver enzymes, and albumin are normal
Lipid Panel: hypercholesterolemia with markedly elevated LDL (178 mg/dL), low HDL (39 mg/dL), and elevated
triglycerides (175 mg/dL). These findings are consistent with mixed dyslipidemia, further increasing his
cardiovascular risk in the setting of CAD and CHF.

Chest X-ray PA and Lateral: cardiomegaly and left-ventricular prominence

Presumptive Diagnosis: Congestive Heart Failure (CHF), likely HFrEF (systolic dysfunction ICD 10 code is
I50.2) 3

The patient’s presentation is most consistent with decompensated congestive heart failure. I came up with the
diagnosis given the patient reporting dyspnea on exertion, orthopnea requiring three pillows, and paroxysmal
nocturnal dyspnea, along with progressive fatigue and low exercise tolerance. Physical findings that support the
diagnosis include bilateral edema of the ankles and shins, bibasilar crackles, and elevated JVP. He has gained 15
pounds in one month, reflecting volume overload. His past medical history of coronary artery disease and
hypertension represents major risk factors, compounded by recent non-adherence to antihypertensive medications.
The feeling of heavy pressure in his chest may be related to reduced blood flow to the heart, which can contribute to
his heart’s weakened pumping function. EKG findings of left ventricular hypertrophy and prolonged QT interval
support the diagnosis as well. BNP is elevated and further supports the diagnosis of moderate congestive heart
failure. The lipid panel, CBC, CMP and PA and lateral chest x-ray findings also support this diagnosis.

Differential Diagnosis: Coronary Artery Disease with Stable Angina / Ischemic Cardiomyopathy 2 (ICD10
code is I25.10):
Given his history of coronary artery disease, hyperlipidemia, description of occasional chest pressure, and ischemic
cardiomyopathy is an important consideration. Fatigue and dyspnea on exertion can be manifestations of poor
myocardial oxygen supply. However, he denies acute or exertional chest pain, which makes ongoing angina less
likely as the primary cause of his current decompensation. This makes CHF more favorable diagnosis, although
CAD remains a significant underlying contributor.

Differential Diagnosis: Chronic Obstructive Pulmonary Disease 1 (COPD- J44.0):

COPD could explain his long-term shortness of breath, cough, and low exercise tolerance, especially with his 38-
pack-year smoking history. But since he quit nearly 30 years ago, does not bring up phlegm, and has no wheezing on
exam, COPD is less likely diagnosis here.

Differential Diagnosis: Interstitial Lung Disease (ILD) / Post-infectious Pulmonary Changes:

The patient reports persistent cough since a viral upper respiratory infection three weeks ago, which raises the
possibility of post-infectious lung changes or underlying interstitial disease. Dyspnea at rest and exertion could also
point to pulmonary pathology. However, the presence of orthopnea, paroxysmal nocturnal dyspnea, elevated JVP,
and S3/S4 gallop strongly suggest a cardiac rather than pulmonary etiology.

Anemia (nutritional or chronic disease)- ICD10 is D64.9: can cause fatigue/DOE; ruled out with normal Hgb/Hct.

Disposition: Admitting the pt for inpatient management of CHF exacerbation with close monitoring. The order is in
progress.

Ordered Medication:

Captopril 12.5 mg PO TID: Start at lower dose; titrate as tolerated up to 25–50 mg TID. Take 1 hour before meals;
use with diuretic.

Carvedilol (Coreg) 3.125 mg PO BID: Must be taken with food; do not stop abruptly. Titrate up every 2 weeks as
tolerated.

Hydrochlorothiazide 12.5–25 mg PO daily: For blood pressure control and mild diuresis.

Atorvastatin 40 mg PO daily: For hyperlipidemia and secondary prevention of CAD.

Aspirin 81 mg PO daily: For CAD prevention, unless contraindicated.

Patient Education: Advised the patient to monitor the daily weight gain; call if weight gain >2 lbs/day or 5
lbs/week. Low-sodium diet and fluid restriction also referred to nutritionist for further assistance with the diet.
Importance of strict medication adherence (education about stopping BP meds without physician guidance).
Smoking cessation reinforced (already quit; continue abstinence). Limit alcohol to ≤1 drink/day.

Address Barriers to Care: There are no barriers to care. The patient has insurance and access to pharmacies; no
financial barriers identified. I ensured health literacy support and provided written CHF education materials.

Consults-referrals: Cardiology for optimization of CHF therapy. Dietician for dietary counseling (sodium and lipid
management).

Follow-Up: Inpatient: Monitor urine output, daily weights, electrolytes. When discharged should follow up with a
cardiologist within 1–2 weeks, primary care in 2–4 weeks for chronic management and risk factor control.

Admission order: 09/09/2025 at 9:10 am

Attending Physician: Last name, First Name.

Ordering provider: Siranush Gharibyan PA-S,

Pt name is NS, age 74 yo (DOB xx/xx/1950)

Admit to Inpatient Medicine Service / Telemetry Unit

Diagnosis: Primary: Congestive heart failure (I50.22 – chronic systolic HF)

Secondary: Hypertension, Coronary artery disease, Hyperlipidemia, Benign prostatic hyperplasia, Cervical arthritis

Condition: Stable but symptomatic; requires monitoring and IV therapy

Activity: Up with assistance as tolerated; daily ambulation encouraged

Vitals: Monitor q4h; strict I/Os; daily weights

Allergies: No known drug or food allergies

Diet:Cardiac diet (low sodium, 2 g/day), 1.5 L/day fluid restriction

Interventions (Nursing/Supportive Care): Oxygen by nasal cannula to maintain SpO₂ > 94%
Telemetry monitoring. Elevate head of bed for orthopnea. Compression stockings as tolerated

Medications: Furosemide 40 mg IV once, then reassess for daily dosing, Captopril 12.5 mg PO TID (titrate as
tolerated), Carvedilol 3.125 mg PO BID with meals (titrate as tolerated), Hydrochlorothiazide 12.5 mg PO daily,
Atorvastatin 40 mg PO daily, Aspirin 81 mg PO daily. PRN: Acetaminophen 650 mg PO q6h for pain/fever;
Ondansetron 4 mg PO/IV q8h for nausea

Procedures:
Echocardiogram to assess EF and wall motion
12-lead ECG now (repeat PRN chest pain)
Chest X-ray (PA/Lateral)
Telemetry

Labs: CBC, CMP, BNP (already elevated at 630), fasting lipid panel, BMP daily while on diuretics, Troponin ×3 if
chest discomfort or ischemia suspected
Special instructions: Monitor daily weights and report >2 lbs/day or >5 lbs/week. Educate on low-sodium diet,
fluid restriction, and strict medication adherence. Cardiology consult for CHF optimization. Nutrition consult for
diet reinforcement. DVT prophylaxis (e.g., compression devices or heparin if not contraindicated).

Works Cited:

1) Agarwal AK, Raja A, Brown BD. Chronic Obstructive Pulmonary Disease. [Updated
2023 Aug 7]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2025
Jan-. Available from: [Link]

2) Centers for Disease Control and Prevention. (2024, May 15). About coronary artery
disease (CAD). Centers for Disease Control and Prevention. [Link]
disease/about/[Link]

3) Shams P, Malik A, Chhabra L. Heart Failure (Congestive Heart Failure) [Updated 2025
Feb 26]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2025
Jan. Available from: [Link]

Electronically Signed by Siranush Gharibyan, PA-S

Supervising Physician: First name and Last name, MD
Date written: 09/09/2025 at 9:30 am
For this note, I used ChatGTP/ Ai only for grammatical error correction.