Advanced Practice Care of Adults NURS 6531-17

Week 3 SOAP Note Student Name Advanced Practice Care of Adults NURS 6531-17 Date This study source was downloaded by from CourseH on :26:21 GMT -05:00 WEEK 3 SOAP NOTE 2 Week 3 SOAP Note Patient Initials: RF Age: 68 Gender: Female SUBJECTIVE DATA: Chief Complaint (CC): Frequent headaches. History of Present Illness (HPI): RF is a 68-year-old African American female who presents with a headache x 2 weeks on a daily basis. She reports that her headache is mostly located in the top of her head, the pain alternates between a dull ache and throbbing pain, and pain intensity varies with each occurrence. She states that she had a moderate upper respiratory infection 1 week prior to the start of her headaches. She denies blurred vision, nasal congestion, sore throat, difficulty swallowing, cough, or difficulty breathing. She has been taking prescribed ibuprofen for pain, which provided temporary relief. She states that the headaches occur 2-3 times daily at various times. Medications: Aspirin 81 mg daily, selenium 200mg daily, multivitamin daily, atorvastatin 40mg daily, diclofenac 75mg daily, ibuprofen 800mg TID, levothyroxine 112mcg daily, Tresiba FlexTouch 200units/ml-20 units subcutaneous BID, losartan potassium 50mg daily, pantoprazole 40mg daily, and metformin 500mg-2tabs daily.