SOAP NOTE Ankles Swelling (NURSING MSN5500) Comprehensive Assessment.

SOAP NOTE Name: S. D. Date: Time: 14:30 ID # Age: 48 Sex: Female SUBJECTIVE CC: “Swelling of the ankles and weakness” HPI: S.D. is a 48 years old female, who came to the clinic today with the complaint of swelling of the ankles since two weeks ago and weakness. The patient was observed to be pleasant and with no acute distress. She is a known hypertensive since five years ago, and after being diagnosed, she kept her treatment and changed her lifestyle. She began exercising consistently, and she began to lose weight. Her blood pressure has been stabilized. The edema of her feet began, but her blood pressure continued stable. She denies suffering from any other disease. She Denies smoking, drinking alcohol, or using another illicit drug. Medications: Amlodipine 10 mg 1 tab po daily (antihypertensive) PMH Allergies: NKA Medication Intolerances: None Chronic Illnesses/Major traumas : Hypertension (401.1) controlled Hospitalizations/Surgeries : Two cesarean sections Family History Mother and father alive, his father is hypertensive and have a history of CAD. His mother has osteoarthritis and obese. The patient has a healthy younger sister. Social History The patient graduated from college and works as a teacher in a middle school. She lives in a residential area with her husband and two children. Denies substance use / abuse, ETOH, tobacco, marijuana. Immunization: Received flu vaccine in November 2015 Environmental hazard: Denies environmental hazard Safety status: She states “I always wear my seatbelt”. She performs self-breast examination each month. Last screen mammogram March 2014 and Pap smear February 2015. Diet: Drinks natural juices, coffee 1/2 cup every morning, and 8 glasses of water daily. Also eat healthily. Exercise and Leisure: She goes to the gym three times throughout the week, and on weekends makes outdoor activities with his family. Sleep: The patient states that she sleeps well.