Walden UniversityNURS 6531NEpisodic SOAP Note Week 6.

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Running head: EPISODIC SOAP NOTE 2 Episodic SOAP Note 2 Alice Kayirangwa NURS 6531N-9 Advanced Practice Care of Adults Walden University July 7, 2019 2 Running head: EPISODIC SOAP NOTE 2 Episo... dic SOAP Note 2 Patient Initials: M. G Age: 37 Gender: F SUBJECTIVE DATA: Chief Complaint: “My stomach has been hurting even more, and nothing seems to help” History of Present Illness: M.G is a 37-year-old- Hispanic female, who presents to the clinic for a follow-up visit on an abnormal abdominal x-ray that was done two weeks ago. The patient continues to complain of lower abdominal pain and states that she does not think it is acid reflux as initially thought because the Prilosec prescribed during the last visit has not helped. She says the pain tends to increase while eating or shortly after a meal. She rates the pain at 6/10 at worst. The pain radiates to the lower back, and at some point, she is unable to do anything but just lay in bed. Denies any other symptoms such as nausea, vomiting, diarrhea, and chest pain. Medications: Effexor XR 37.5 mg 1 cap daily Zofran 4 mg ODT 1 tab every 6 hrs as needed Cyclobenzaprine 5 mg 1 tab three times daily as needed Mobic 15 mg 1 tab twice daily Lisinopril /HCTZ 20 mg 1 tab daily Protonix 40 mg 1 tab twice daily Wellbutrin XL 150 mg 1 tab twice daily Tramadol HCL 50 mg 1 tab every 8 hrs as needed Inderal XL 80 mg 1 tab daily Vitamin D 500000-unit 1 cap weekly [Show More]

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