NURS 3150 soap note Fall 2023

NURS 3150 soap note Fall 2023 Subjective Data A. Chief Complain (CC): “I need a primary care doctor and I also have an injury to my toe” B. History of Present Illness (HPI): C. Last Menstrual Period– Not applicable. D. Allergies: NKDA E. Past Medical History: Hypertension and diabetes II F. Family History: Father – Diabetes and Glaucoma Mother – Hypertension G. Surgery History- None H. Social History- Denies drug use, alcohol and tobacco use, Erickson developmental stage generativity vs. stagnation. Patient is married (1 sexual partner) with three kids and 5 grandchildren. I. Health Maintenance: Last eye exam 2022, Pt unable to provide information on immunization history J. Lifestyle Patterns: Does not exercise or eat healthy, use seatbelts, good hand hygiene. Sleeps 8 hours daily, no caffeine or OTC use K. Current medications: amlodipine 10mg daily, gabapentin 300mg BID HYDROCHLOROTHIAZIDE 25MG daily, rosuvastatin 5mg daily Humulin 50units during day and 50 units at night, lisinopril 40mg daily. No OTC