NURS 6531 Week 4 Assigment Part 3 2021|Walden University

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NURS 6531 Practicum Experience Journal SOAP NOTE: HYPERTENSION 2 Patient Initials: XX SUBJECTIVE DATA: | Age: 31 | Gender: FChief Complaint (CC): “I’m here for my follow up on my blood press... ure, and to review my labs.” History of Present Illness (HPI): XX is 31-year-old African American with new onset of diabetes and hypertension. Alert and oriented. Denies any history of any other discomfort. Return to clinic for two weeks follow-up for newly diagnosed high blood pressure and diabetes. Medications: Lisinopril10mg daily Metformin 500mg twice daily Allergies: Denies Allergies Past Medical History (PMH): Hypertension, Type 2 Diabetes. Past Surgical History (PSH): Denies Surgical History. Report only hospitalization is for childbirth. Personal/Social History: Pt. is a married mother of three who works part-time in retail. Resides in a three-bedroom home with husband and three children. Pt. has been married for 5 years. Husband is employed as a trucker and spend a lot of time on the road. Children are 4-year-old daughter, 9-year-old son, and 11-year-old daughter. Pt. report it is a monogamous relationship. Denies alcohol, tobacco, or illicit drug use. Denies exposure [Show More]

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