Walden UniversityNURS 6531Compreh SOAP NOTE Example.

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SOAP Note 2 SOAP NOTE: Patient Initials: D.P. Age: 71 Gender: Female SUBJECTIVE DATA: Chief Complaint (CC): "Here for a follow up and to discuss my back." History of Present Illness (HPI): 71 ye... ar old Caucasian female who presents for 6 month follow up. She has a history of hypertension which is controlled with medication. She denies any vision changes, dizziness, headaches, or vertigo. She reports bilateral lower back pain that has been present for approximately 2 weeks. She reports that her pain is intermittent and is pressure like. She denies any pain traveling down her legs. She reports that her pain is increased with activity. She reports taking Ibuprofen occasionally with pain relief. She rates her pain at this time as a 2/10 on the pain scale. She reports that she was seen yesterday by a chiropractor and had an adjustment. She states that her pain is improved today. She denies any fever, chills, nausea, vomiting, pain with urination, hematuria, foul smelling urine, urinary frequency or urgency. She also reports concerns regarding weight gain and wishes to discuss weight loss options. She denies any changes in her eating or exercise habits. She denies attempting a diet or exercise regimen. She does admit to eating sweets often, and sometimes eating an entire box of "cakes" as well as other sugary foods. She is wondering if a diet pill would be a good fit for her and is wondering if another blood pressure medication needs to be added due to weight gain. Medications: Aspirin 81 mg po daily Black Cohosh root Extract 160 mg po daily Zyrtec 10 mg po daily Lisinopril/HCTZ 20-12.5 mg po daily Meloxicam 15 mg po daily Potassium Chloride IO meq ER po daily Zocor 10 mg po daily Vitamin C 250 mg po daily Vitamin B-12 1000 mcg po daily Premarin vaginal cream Allergies: Codeine - anaphylaxis : severe allergy. [Show More]

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