NURS 634 SOAP NOTE 3 Cardiovascular History and Physical Examination

SOAP # 3: Cardiovascular APN, PNP-AC UMASS History & Physical Examination Patient Demographics: Name: A.B. Age/race/sex: 47 Hispanic Female Clinical site: Primary Care clinic SUBJECTIVE DATA Chief Complaints: “My feet have been really swollen and painful since about Sunday. It hurts to just put on my shoes and walk for long periods of time”. History of Present Illness: Ms. B a 69 y/o female with a long-standing history of uncontrolled HTN, dyslipidemia, and Type II DM. Presents to the clinic today with a 3-day history of BLE edema localized to the feet, intermittent claudication, and pain with deep touch to the area. Patient reports she begin to recognize on Sunday that it was more difficult for her to put on her shoes when getting ready for church. However, she was able to get them on but with some resistance and discomfort. On Monday, patient noticed they were about 40% bigger than Sunday and had begun to become more painful with touch and with walking, so much so that she needed assistance with her rollator during ambulation. The grand-daughter then called the clinic to set up an appointment for today. The pain is localized to the anterior feet and toes but does radiate to the calves when walking only. Pain described as throbbing in the feet and sharp, shooting in the calves, rated a 10/10 in both areas, and patient states the pain is intermittent throughout the day but is worse when walking and with touch or pressure. Patient also reports some intermittent numbness and tingling to BLE that’s worse after sitting. Past Medical History: Hypertension-active and uncontrolled. Diabetes-active and uncontrolled. Dyslipidemia-active uncontrolled. Past Surgical History: Hernia repair-2004 with no complications. Hysterectomy at age 45 with no complications. Allergies: NKA to food, medication, environmental, or seasonal allergies. Medications: Norvasc 10 mg 1 tab by mouth daily Hydroclothiazide 25 mg 1 tab by mouth daily Metformin 850 mg 1 tab by mouth twice daily Crestor 20 mg by mouth in the evening Novolog Insulin 100uints/ml- take 20 units in the morning before breakfast; 30 units in the evening before dinner. Health Maintenance: Agreed to get Influenza vaccine today. Received Pneumococcal vaccine last year (2016) around Feb. All other immunizations are up-to-date including TDaP, MMR, Varicella, and Shingles.