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Subject: – Nursing


Practicum Experience: SOAP Note and Journal

In addition to Journal Entries, SOAP Note submissions are a way to reflect on your Practicum Experiences and connect these experiences to your classroom experience. SOAP Notes, such as the ones required in this course, are often used in clinical settings to document patient care. Please refer to the Seidel, et. al. book excerpt and the Gagan article located in this week’s Learning Resources for guidance on writing SOAP Notes.
Patient Office Visit
Patient Name: B.N
DOB: … AGE: 79 Sex: Female, Visit date: 6/14/16
Vital signs: BP=180/80, Temp=98.4, P=72, RR=20, Weight=241 height: 65 in, BMI=39.44, Spo2=97% room air.
Chief Complain: I have not been feeling too good for 5 days now. “I feel like my blood pressure is off the hook because my head feel heavy”

History of Present Illness (HPI): B.N is a 79 year old African American female who presents today with complaint of feeling heavy on her head. She reported I have not been feeling too good for 5 days now. “I feel like my blood pressure is off the hook because my head feels heavy” Patient did not take her antihypertensive medications before coming to the office.

1.) Acetaminophen-codeine (Tylenol with codeine #3) 300 mg-30 mg oral tablet bid prn starting 6/14/16
2.) Asprin 81 mg oral tablet daily
3.) Cholecalciferol (vitamin D3) 1000 intl units oral capsule daily before meal
4.) Clonidine HCL 0.2 mg oral tablet three times daily. M.D discontinued clonidine patch on 6/14/16 during this visit.
5.) Hydralazine HCL 100 mg oral tablet three times daily, Patient used to take 75 mg bid but was adjusted 6/14/16 during this visit.
6.) Linaclotide (Linzess) 145 MCG oral capsule daily on an empty stomach before first meal of the day.
7.) Losartan (Losartan Potassium) 100 mg oral tablet daily


Past Medical History (PMH):
1.) Obesity
2.) Hypertension -uncontrolled
3.) PAD
4. VITAMIN D defciency
5.) Lumbar spondylosis
6. Parathyroid adenoma
7. Malignant tumor of thyroid gland
8. Chronic left knee pain

Past Surgical History (PSH):
1.) Right eye less implant 3/20/2015
2.) Left eye cataract removed 1/16/16
3.) Parathyroid adenoma 2015
4.) Thyroidectomy 2015
5.) Peripheral arterial disease status post anoplasty
Significant Family History:
Three sisters – one with diabetes, dx at age 65, and the other with HTN, dx at age 55 and 60. She has one daughter in her 50s recently diagnosed with HTN and son 56 DM. Mother died of complication from HTN age 80 years and father Dm age 77 years.

Personal History: Denies smoking, use of drugs.
Skin: Intact

Mental Status: alert and oriented to person, place, and time.

Note: follow other systems per SOAP. They are within limit. Avoid abreviations.

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