CONPH NSG6320/NSG6420 Subjective, Objective, Assessment, Plan (SOAP) Notes
Student Name: Edgar C. Harvey Jr. Course: NSG 6420
Patient Name: S.J Date: 7/30/24 Time: 0916
Ethnicity: Hispanic Age: 68 Sex Female
SUBJECTIVE (must complete this section)
CC: swelling and pain to client right leg
HPI: The patient presents to the clinic feeling much pain and swelling in her right leg for the past five
days. The leg is swollen, resulting in changes in the color of the right leg to reddish. She reports chest
pain, which worsens whenever she takes a deep breath. Consequently, she experiences rapid breathing
whenever she takes a deep breath. On a scale of 1 to 10, the patient rates the pain as 7/10. She reports
having taken diclofenac to relieve the pain in vain. The patient reports that the pain aggravates when she
keeps standing for long hours and does not seem to go always any time soon. Pt. reports to have smoked
tobacco and stopped it one year ago. She denies any history of licit drugs, hospitalization, or surgeries.
Pt. reports a history of congestive heart failure in her late mother and hypertension, which claimed the
life of her father 2 years ago. She denies any past diagnosis or surgery related to cancer. She reports
retiring as a telecommunications oHicer, and her current state of health is very demanding, especially
regarding her time and resources. She admits to rarely undertaking physical exercise.
Medications: Diclofenac
Previous Medical History:
Allergies: none
Medication Intolerance: none
Chronic Illnesses/Major traumas: none
Hospitalizations/Surgeries: none
FAMILY HISTORY (must complete this section)
M: died from high blood pressure
MGM: died old age
MGF: died of cancer
F: died from CHF
PGM: unknown
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, PGF: unknown
Social History: The patient is a mother of four and a retired telecommunications oHicer. She is a
university graduate. She lives with her husband, a retired teacher, and is at peace. She feels safe and
appreciated by her family. She denies illicit drug use and admits having been a smoker but stopped one
year ago.
REVIEW OF SYSTEMS (must complete this section)
General: She denies weight changes, night sweats, Cardiovascular: Pt. admits feeling chest pain
changes in energy level, chills, fever, or fatigue. whenever she takes a deep breathe. She reports
having intermittent fast breathing. Pt. denies edema,
palpitations, chest pain, or orthopnea.
Skin: warm and dry Respiratory: Pt. reports having dyspnea. Pt. denies
TB, cough, dyspnea, wheezing, hemoptysis or
pneumonia history.
Eyes: PEARL Gastrointestinal: reports n/v, denies bm changes or
abd pain
Ears: She denies pain in the ears, hearing problems, Genitourinary/Gynecological: denies urinary
ear discharges, ringing in the ears, or hearing loss. frequency, pain, hematuria or any diHiculties
Nose/Mouth/Throat: Pt. denies throat pain, nose Musculoskeletal: Pt. complains of swelling in her
bleeding, sinus issues, dental diseases, dysphagia, or right leg. She denies delay in rash healing, bruising
hoarseness. of the skin, rashes in the skin, bleeding or any lesion
changes.
Breast: neg sbe, lumps, bumps or any change Neurological: CAOx3
Heme/Lymph/Endo: neg findings Psychiatric: none
OBJECTIVE (Document PERTINENT systems only, Minimum 3)
Weight: 178 Height:5’2 BMI: 26 BP: Temp: 98.6 Pulse:82 Resp: 18
138/72
This study source was downloaded by 100000892566046 from CourseHero.com on 11-02-2024 15:48:19 GMT -05:00
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