Walden UniversityNURS 6540FSOAP Note

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Running head: COMPREHENSIVE SOAP NOTE 1 SOAP Note Comprehensive SOAP Note Walden University Advanced Practice Care of Frail Elders NURS-6540F Comprehensive SOAP Note Patient Initials: _W.L._ Age:... __72__ Gender: ___M__ COMPREHENSIVE SOAP NOTE 2 Subjective Data Chief Complaint (CC): “I’m cold” History of Present Illness (HPI): 72-year-old Caucasian male admitted to this facility under a Baker Act for suicidal ideation and inability to care for himself. He lives with his wife who says that he has not been eating well for about a week. Medications: Home medications include: Carafate 1 gram PO QID, Zoloft 50 mg PO daily, Lipitor 80 mg PO QHS, Protonix 40 mg PO daily, multivitamin 1 tab PO daily, Flomax 0.4 mg PO daily, Plavix 75 mg PO daily, Aspirin 81 mg PO daily, Atenolol 50 mg PO daily, and folic acid 1 mg PO daily. The Beer’s criteria tool was developed to improve medication safety among the elderly. After reviewing this patient’s current medications and comparing them with the Beers Criteria, I have discovered that the medications this patient is taking are appropriate for his age. (American Geriatrics Society, 2015). Allergies: NKDA Past Medical History (PMH): HTN, BPH, High cholesterol, COPD, Stroke, Dysphagia, ETOH dependence Past Surgical History (PSH): Patient denies Personal/Social History: Patient reports he quit smoking 1-2 years ago. He drinks 6 beers daily Immunization History: Unknown Significant Family History: unknown Review of Systems: General: Patient lying in bed under the covers. He appears disheveled, thin, and dirty. He reports chills and some weight loss but denies fever. [Show More]

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