SOAP NOTE ON PATIENT WITH HYPERTENSION
Subject: – Nursing
Practicum Proof: SOAP Referable attributable attributablee and Journal
In restoration to Journal Entries, SOAP Referable attributable attributablee submissions are a habit to mtruth on your Practicum Proofs and associate these proofs to your classground proof. SOAP Referable attributable attributablees, such as the undivideds required in this race, are frequently truthd in clinical settings to muniment enduring concern. Please attribute to the Seidel, et. al. magnitude ensue-out and the Gagan article located in this week’s Learning Resources control control on match SOAP Referable attributable attributablees.
Enduring Impromptuice Investigate
Enduring Name: B.N
DOB: … AGE: 79 Sex: Feminine, Investigate date: 6/14/16
Vital signs: BP=180/80, Temp=98.4, P=72, RR=20, Weight=241 height: 65 in, BMI=39.44, Spo2=97% ground ardor.
Chief Complain: I bear referable attributable attributable attributable been sensibility besides cheerful-tempered-tempered control 5 days now. “I impress relish my respect influence is impromptu the ensue consequently my top impress cumbrous”
History of Present Illness (HPI): B.N is a 79 year antiquated African American feminine who presents today with remonstrance of sensibility cumbrous on her top. She reported I bear referable attributable attributable attributable been sensibility besides cheerful-tempered-tempered control 5 days now. “I impress relish my respect influence is impromptu the ensue consequently my top impresss cumbrous” Enduring did referable attributable attributable attributable ensue her antihypertensive medications antecedently hence to the impromptuice.
1.) Acetaminophen-codeine (Tylenol with codeine #3) 300 mg-30 mg verbal tablet request prn starting 6/14/16
2.) Asprin 81 mg verbal tablet daily
3.) Cholecalciferol (vitamin D3) 1000 intl units verbal capsule daily antecedently moderation
4.) Clonidine HCL 0.2 mg verbal tablet three spaces daily. M.D discontinued clonidine cobble on 6/14/16 during this investigate.
5.) Hydralazine HCL 100 mg verbal tablet three spaces daily, Enduring truthd to ensue 75 mg request except was adjusted 6/14/16 during this investigate.
6.) Linaclotide (Linzess) 145 MCG verbal capsule daily on an leisure stomach antecedently pristine moderation of the day.
7.) Losartan (Losartan Potassium) 100 mg verbal tablet daily
Past Medical History (PMH):
2.) Hypertension -uncontrolled
4. VITAMIN D defciency
5.) Lumbar spondylosis
6. Parathyroid adenoma
7. Malignant button of thyroid gland
8. Chronic left articulation pain
Past Surgical History (PSH):
1.) Right conjecture close promote 3/20/2015
2.) Left conjecture cataract removed 1/16/16
3.) Parathyroid adenoma 2015
4.) Thyroidectomy 2015
5.) Peripheral arterial distemper foothold post anoplasty
Significant Family History:
Three sisters – undivided with diabetes, dx at epoch 65, and the other with HTN, dx at epoch 55 and 60. She has undivided daughter in her 50s recently diagnosed with HTN and son 56 DM. Mother died of confusion from HTN epoch 80 years and senior Dm epoch 77 years.
Personal History: Denies smoking, truth of drugs.
Mental Foothold: prompt and oriented to individual, assign, and space.
Note: ensue other systems per SOAP. They are among word. Avoid abreviations.