NRNP 6540 Week 10 Focus SOAP Note- Musculoskeletal/Neurological

NRNP 6540 Week 10 Focus SOAP Note- Musculoskeletal/Neurological Jamie Boggs NRNP 6540 Dr. Petko Walden University May 10, 2021 Week 10 Focused SOAP Note- Musculoskeletal/Neurological Patient Information: M.L., 66 y.o., Male, Hispanic S (subjective) CC (chief complaint): Acute aphasia, right facial droop, and right-sided weakness. HPI (history of present illness): M.L., is a 66 y.o., Hispanic, male who presents to the ED after EMS was called by a co-worker for acute aphasia, right facial droop, and right-sided weakness. LKW 1 hour ago. Mr. Lopez’s wife is present on arrival and reports a Hx. of uncontrolled HTN and newly diagnosed DM. She also reports non-compliance with HTN medications. Current Medications: Lisinopril 10mg PO Daily Metformin 500mg PO BID Allergies: NKDA. No known food or environmental allergies. PMHx: Uncontrolled HTN, DM, Smoker. Last Tetanus booster May 2018. All other age- appropriate immunizations current. Soc and Substance Hx: Mr. Lopez is a 66 y.o., male who works at the local post office part time. He lives with his wife Lucinda of 29 years and their two dogs. He and his wife have two adult children, one is 32 y.o. and lives locally, the other is 38 and lives in California. Mr. Lopez is a current ½ PPD smoker of 30 years. He drinks 1-2 beers/week. Denies current or former illicit drug use. Mr. Lopez lives a sedentary lifestyle to which his weight gain is attributed. Fam Hx: Father- Deceased 67 y.o., MI. Mother- Deceased 69 y.o., MI. Paternal Grandmother- Living, 88 y.o., DM, HTN, HLD. Paternal Grandfather- Deceased, 83 y.o., COPD. Maternal Grandmother- Deceased, 76 y.o., CVA. Maternal Grandfather- Deceased, 71 y.o., MI. Surgical Hx: No past Sx. Hx. Mental Hx: No past or current Hx. of mental illness. No current or past Hx. of anxiety or depression. Violence Hx: No current or past Hx. of physical, emotional, sexual or financial abuse. Reports feeling safe at home.