Soap Note # Main Diagnosis ( Exp: H&P Note #3 DX: Hypertension)

Student Name

Miami Regional University

Date of Encounter:

Preceptor/Clinical Site:

Clinical Instructor: Dr. Rafael Camejo

Soap Note # Main Diagnosis ( Exp: Soap Note #3 DX: Hypertension)

PATIENT INFORMATION

Name: Mr. DT

Age: 68-year-old

Gender at Birth: Male

Gender Identity: Male

Source: Patient

Allergies: PCN, Iodine

Current Medications: 

Atorvastatin tab 20 mg, 1-tab PO at bedtime

ASA 81mg po daily

Multi-Vitamin Centrum Silver

PMH: Hypercholesterolemia

Immunizations: Influenza last 2018-year, tetanus, and hepatitis A and B 4 years ago.