Walden UniversityNURS NUR 6531Episodic SOAP Note 1.

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Running head: EPISODIC SOAP NOTE Episodic SOAP Note 1 Alice Kayirangwa NURS 6531N-9: Advanced Practice Care of Adults Walden University June 13, 2019 2 Running head: EPISODIC SOAP NOTE Episodi... c SOAP Note 1 Patient Initials: A.M Age: 66 Gender: M SUBJECTIVE DATA: Chief Complaint (CC): “My legs are really hurting and swollen, and I have been having a hard time walking” History of Present Illness (HPI): A.M is a 66 y/o male who comes into the clinic complaining of lower extremities edema and increased fatigue and difficulty walking. Patient states that he noticed the leg swelling a week ago, however, the pain started 3 days ago. Patient took over the counter Tylenol 500 mg every 8 hours with mild relief. Patient reports that his pain gets worse with walking. He rates his pain as 8/10. Also, Patient reports SOB, and is expressing concerns for too much weight gain and states he has not been taking his prescribed water pill Furosemide 40 mg daily because it makes him urinate constantly. Current Medications: Amlodipine 10mg daily Atorvastatin 40mg daily Calcitriol 0.5 mcg Oral 2 capsules daily Carvedilol 12.5mg daily Clonidine HCl 0.1 mg as needed Cyclobenzaprine HCl 5mg 2 tabs q 8h as needed Furosemide 40 mg daily Gabapentin 600mg BID Glimepiride 2mg in AM Hydralazine HCl 100mg TID 3 Running head: EPISODIC SOAP NOTE Lubricant eye drops 0.4 mg BID Tizanidine 2mg BID Trazodone HCl 150mg daily at bedtime Vitamin D 50000UNT daily [Show More]

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