Running head: EPISODIC SOAP NOTE
Episodic SOAP Note 1
Alice Kayirangwa
NURS 6531N-9: Advanced Practice Care of Adults
Walden University
June 13, 2019
2
Running head: EPISODIC SOAP NOTE
Episodic SOAP Note 1
Patie
...
Running head: EPISODIC SOAP NOTE
Episodic SOAP Note 1
Alice Kayirangwa
NURS 6531N-9: Advanced Practice Care of Adults
Walden University
June 13, 2019
2
Running head: EPISODIC SOAP NOTE
Episodic SOAP Note 1
Patient Initials: A.M Age: 66 Gender: M
SUBJECTIVE DATA:
Chief Complaint (CC): “My legs are really hurting and swollen, and I have been having a hard
time walking”
History of Present Illness (HPI): A.M is a 66 y/o male who comes into the clinic complaining
of lower extremities edema and increased fatigue and difficulty walking. Patient states that he
noticed the leg swelling a week ago, however, the pain started 3 days ago. Patient took over the
counter Tylenol 500 mg every 8 hours with mild relief. Patient reports that his pain gets worse
with walking. He rates his pain as 8/10. Also, Patient reports SOB, and is expressing concerns for
too much weight gain and states he has not been taking his prescribed water pill Furosemide 40
mg daily because it makes him urinate constantly.
Current Medications:
Amlodipine 10mg daily
Atorvastatin 40mg daily
Calcitriol 0.5 mcg Oral 2 capsules daily
Carvedilol 12.5mg daily
Clonidine HCl 0.1 mg as needed
Cyclobenzaprine HCl 5mg 2 tabs q 8h as needed
Furosemide 40 mg daily
Gabapentin 600mg BID
Glimepiride 2mg in AM
Hydralazine HCl 100mg TID
3
Running head: EPISODIC SOAP NOTE
Lubricant eye drops 0.4 mg BID
Tizanidine 2mg BID
Trazodone HCl 150mg daily at bedtime
Vitamin D 50000UNT daily
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