Walden UniversityNURS NUR 6531Comprehensive SOAP Note

Document Content and Description Below

Running head: COMPREHENSIVE SOAP NOTE Comprehensive SOAP Note Alice Kayirangwa NURS 6531N-9 Advanced Practice Care of Adults Walden University Friday, July 19, 2019 2 Running head: COMPREHENSIV... E SOAP NOTE Comprehensive SOAP Note Patient Initials: F. C Age: 67 Gender: F SUBJECTIVE DATA Chief of Complain: “My back has been hurting more than usual, and I have had two falls in the last week” History of Present Illness: F.C is a 67-year-old Caucasian female, who came into the clinic complaining of low back pain and weakness. Patient stated that the back pain has been increasingly worse and hurting more than usual. Patient describes the pain as an aching pain in the lower back region. Patient stated that the pain started getting worse about a week ago and that the pain increases with any type of activity especially lifting. F.C rates her pain as 8/10 on a 1-10 scale. Patient stated that the pain sometimes radiates to the buttocks and down into the legs. Patient states that she took Tramadol 50 mg every eight hours as needed for pain, but the pain keeps coming back. Patient states that the pain sometimes is relieved by lying down in supine position. Patient also reported generalized weakness, and two falls in the last week. Patient denies any injuries related to the falls. [Show More]

Last updated: 1 year ago

Preview 1 out of 15 pages