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 Initia
...
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
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