CH is a 55y/o female came in to the clinic with her nephew after a 4-hour history of “feeling bad.” Pt reported chest pain, tiredness, generalized weakness. She refused to eat or drink anything since this morning due to fatigue. Pt’s nephew wife reported she appears sweaty even though he has not done much all day. Pt’s on hydrocodone/acetaminophen 10/325 mg for chronic lower-back pain, and this has not relieved her current symptoms.
Do your assessment and write SOAP note using the template below