Running head: EPISODIC SOAP NOTE 2
Episodic SOAP Note 2
Alice Kayirangwa
NURS 6531N-9 Advanced Practice Care of Adults
Walden University
July 7, 2019
2
Running head: EPISODIC SOAP NOTE 2
Episodic SOAP Note 2
Pat
...
Running head: EPISODIC SOAP NOTE 2
Episodic SOAP Note 2
Alice Kayirangwa
NURS 6531N-9 Advanced Practice Care of Adults
Walden University
July 7, 2019
2
Running head: EPISODIC SOAP NOTE 2
Episodic SOAP Note 2
Patient Initials: M. G Age: 37 Gender: F
SUBJECTIVE DATA:
Chief Complaint: “My stomach has been hurting even more, and nothing seems to help”
History of Present Illness: M.G is a 37-year-old- Hispanic female, who presents to the clinic for
a follow-up visit on an abnormal abdominal x-ray that was done two weeks ago. The patient
continues to complain of lower abdominal pain and states that she does not think it is acid reflux
as initially thought because the Prilosec prescribed during the last visit has not helped. She says
the pain tends to increase while eating or shortly after a meal. She rates the pain at 6/10 at worst.
The pain radiates to the lower back, and at some point, she is unable to do anything but just lay
in bed. Denies any other symptoms such as nausea, vomiting, diarrhea, and chest pain.
Medications:
Effexor XR 37.5 mg 1 cap daily
Zofran 4 mg ODT 1 tab every 6 hrs as needed
Cyclobenzaprine 5 mg 1 tab three times daily as needed
Mobic 15 mg 1 tab twice daily
Lisinopril /HCTZ 20 mg 1 tab daily
Protonix 40 mg 1 tab twice daily
Wellbutrin XL 150 mg 1 tab twice daily
Tramadol HCL 50 mg 1 tab every 8 hrs as needed
Inderal XL 80 mg 1 tab daily
Vitamin D 500000-unit 1 cap weekly
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