Walden UniversityNURS 6540Week3SOAPNote.

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Running head: WEEK 3: SOAP NOTE 1 Week 3: SOAP Note Esperanza Macalincag Walden University Advanced Practice Care of Frail Elders NURS 6540 September 16, 2018 WEEK 3: SOAP NOTE 2 Week 3: SOAP ... Note Patient Initials: L.S. AGE: 78 Gender: Male Race: Caucasian SUBJECTIVE DATA: Chief Complaint (CC): According to the patient’s wife “He started with a cough morning and became confused this afternoon.” He also has a mild fever. History of Present Illness (HPI): L.S. is 78-year-old Caucasian male presented with family including wife and son assisted with history taking. Around 10:30 AM, L.S. suddenly was unable to walk, with slurred speech, and generalized weakness. Wife reports patient has a mild episode of a nonproductive cough early this morning. The cough episode was on and off, not accompanied by shortness of breath or chest pain. The bouts of cough were relieved without any medication or measures done. Wife claimed notice that her husband is not acting right this afternoon. He has a history of Alzheimer’s disease but no episodes of altered mental status and just been seen by the neurologist last month. Past Medical History: 1. Alzheimer’s disease 2. Hypertension 3. Hyperlipidemia 4. GERD 5. Vasculitis 6. Cellulitis Past Surgical History: 1. Tonsillectomy 2. Colonoscopy 2000 Current Home Medications: 1. Amlopidine 5mg, 1 tablet P.O. daily 2. ASA 81mg, 1 tablet P.O. daily 3. Avalide 150mg/12.5mg, 1 tablet P.O. daily 4. Donepezil 10mg. 1 tablet P.O. daily at night 5. Namenda 10mg, 1 tab twice a day 6. Omeprazole 20mg (delayed release) 1 tablet P.O. daily 7. Potassium chloride 20mEq (XR), 1 tablet P.O. daily 8. Simvastatin 20mg, 1tablet daily at night Allergies: WEEK 3: SOAP NOTE 3 Medications: No known drugs allergy Foods: No food allergies Environmental: None Health Maintenance: Annual exam – July 5, 2018. Follows with his neurologist every 6 months and he was last seen August 16, 2018. Immunization: 1. Tetanus/diphtheria/pertussis (Tdap) - 7/27/2017 2. Influenza virus vaccine (inactivated) – 11/10/2017 3. Pneumococcal 13-valent conjugated vaccine – 05/07/2013 4. Pneumococcal 23-polyvalent vaccine – 04/23/2013 Personal/Social History: He lives with his wife. His two son lives across the street with them. He is a retired mechanics and still drives occasionally to doctor’s clinic with the wife. Never smokes. Does not drink alcohol. Denies any illicit drug use. Family History: Family history is negative and not pertinent to the patient’s care currently. Review of System: General: No fever, chills and night sweats. No weight loss, weight gain. HEENT:  Head: No dizziness, fainting, head injury  Eyes: Wears eyeglasses. No recent visual problems. No blurred vision or double vision  Ears, Nose, Mouth, Throat: No ear pain, nasal congestion, oral sores, and sore throat Lymphatic: No lymph tenderness or enlargement SKIN: No rashes, sore, skin itching, or unusual moles Cardiovascular: No chest pain, palpitation, or dyspnea. He sleeps with one pillow and no lower extremities swelling. Respiratory: No shortness of breath, wheezing, cough. Wife claimed he only starts coughing this morning. He does not wear oxygen, not been told to have sleep apnea, and he does not snore. Gastrointestinal: No nausea, vomiting, diarrhea, constipation, abdominal pain or swallowing difficulty. With occasional heartburn to certain foods. No blood in the stools. Bowel movement is regular. His appetite is good. Genitourinary: No incontinence, urgency, dysuria. No polyuria, or blood in the urine [Show More]

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