SU_NSG6420_W4_A5_Taylor_A.docx - SOAP NOTE Name BL Date Age 62 Time 12:30 Sex F SUBJECTIVE CC \u201cLeft leg pain nausea SOB lethargic weight loss\u201d HPI

SU_NSG6420_W4_A5_Taylor_A.docx - SOAP NOTE Name BL Date Age...

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SOAP NOTE Name: BL Date: 11/26/18 Time: 12:30 Age: 62 Sex: F SUBJECTIVE CC: “Left leg pain, nausea, SOB, lethargic, weight loss” HPI: 64-year-old patient with a long hx of mental illness comes in with complaints of Lt leg pain that stems from a piece of the ceiling falling on her leg during a hospital visit. Pt states that the pain is a 10/10 and has continuously worsened over the last 3 weeks. The pain is throbbing in nature and is constant with any movement aggravating the symptoms. The patient states at the time of the incident, the hospital did an x- ray of her left leg and treated her with medication and she was discharged. Medications: Trazodone 50 mg po – Sleep Methotrexate 2.5mg po – RA Carafate 100mg po – Ulcer Folic Acid 1 mg po – supplement Maxzide 37.5/25mg po – HTN Zofran 4mg po – nausea Norvasc 10mg po – HTN Plaquenil 200mg po – SLE
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Amitiza 24 mcg po – IBS Ambien 10 mg po – sleep Tramadol 50 mg po – pain Proair HF 90 mcg inhaler – asthma Symbicort 160- 4.5 mcg inhaler – asthma
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  • Summer '16
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