Comprehensive SOAP Note Alice Kayirangwa NURS 6531N-9 Advanced Practice Care of Adults Friday, July 19, 2019 Comprehensive SOAP Note Patient Initials: F. C Age: 67 Gender: F SUBJECTIVE DATA... Chief of Complain: “My back has been hurting more than usual, and I have had two falls in the last week” History of Present Illness: F.C is a 67-year-old Caucasian female, who came into the clinic complaining of low back pain and weakness. Patient stated that the back pain has been increasingly worse and hurting more than usual. Patient describes the pain as an aching pain in the lower back region. Patient stated that the pain started getting worse about a week ago and that the pain increases with any type of activity especially lifting. F.C rates her pain as 8/10 on a 1-10 scale. Patient stated that the pain sometimes radiates to the buttocks and down into the legs. Patient states that she took Tramadol 50 mg every eight hours as needed for pain, but the pain keeps coming back. Patient states that the pain sometimes is relieved by lying down in supine position. Patient also reported generalized weakness, and two falls in the last week. Patient denies any injuries related to the falls. Medications: ALPRAZOLAM TAB 0.5MG 1 tablet by mouth three times per day as needed AMLODIPINE TAB 10MG 1 tablet by mouth once daily ASPIRIN TAB 81MG EC 1 tablet by mouth once daily BUSPIRONE TAB 15MG 1 tablet by mouth at bedtime CLONIDINE HCL 0.52 mg 1 tablet by mouth once daily DOCUSATE SOD CAP 100MG 1 tablet by mouth once daily FLONASE ALGY SPR 50MCG 1 spray in each nostril once daily GABAPENTIN CAP 100MG 1 tablet by mouth three times per day LIPITOR TAB 10MG 1 tablet by mouth at bedtime METFORMIN TAB 500MG 1 tablet by mouth twice daily METOPROLOL SUCCINATE ER 25mg 1 tablet by mouth once daily NAPROXEN TAB 500MG 1 tablet by mouth twice daily TRAMADOL HCL TAB 50MG 1 tablet by mouth twice daily as needed Allergies: NKDA Past Medical History (PMH): Hypertension, Hyperlipidemia, Peripheral Neuropathy, Anxiety, Depression, Chronic constipation, Osteoarthritis, Lower back pain, Seasonal allergies, Type 2 Diabetes Mellitus, Unstable gait, Vitamin D deficiency. Past Surgical History (PSH): Tonsillectomy, Wisdom teeth removal, and Breast biopsy 7 years ago that was negative. Personal/Social History: F.C is a widowed woman, whose husband passed away 6 years ago. She is a retired high school teacher, who was very active until the last 3 years when her health started to deteriorate. Patient recently moved into an Assisted leaving facility because she did not feel comfortable living by herself and she needed some help. Patient stated that she tries to walk around the building every other day if she is not in pain. She still manages her activities of daily living with minimum assistance from the staff. Patient denies tobacco use and illicit drug. Patient-reported occasional drinking (1-2 glasses of wine per week). Patient eats healthy a lot of fruit and vegetables and eats her sweet pound cake at least 3 times a week. Patient takes multivitamin and vitamin D daily. Denies the use of herbs or any other alternative medicine. Family History: Her mother had PMH of DM, HTN, and breast cancer, she passed away 10 years ago from breast cancer. Father had PMH of Chronic kidney disease and HTN, died 8 years ago from kidney failure. She has 2 living adult children, one girl who is 45 years old with no medical problems, and one son 37 years old with a history of diabetes type 2 and tobacco depended for 5 years. She has 3 grandkids. Health Maintenance: Patient has been menopausal for about 15 years. The last Mammogram was 2 years ago. She does breast self-exam every month. Since her mother died from breast cancer. Patient gets her breast checked every other year for cancer gene screening and she had a biopsy done 7 years ago. The biopsy was negative for breast cancer .........................................................CONTINUED.................................................................... [Show More]
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