NURS 5120Comprehensive SOAP Note 5210 week 2
Module 2: Comprehensive SOAP Note
Katherine A. Wilcoxson
University of Texas at Arlington
In partial fulfillment of the requirements of
NURS 5120-436 Adult-Gerontology Assessment
Course Faculty: Jennifer Robb, MSN, ANCP, ANCC
March 3, 2021
, SOAP 2
SOAP Note Form
S/ Identifying Information: (initials, Family Hx:
age/DOB, gender, reliability)
This is Mrs. C.W., a 64-year-old
Mrs. C.W. was an only child; her parents are both decreased. She
Caucasian female. She is a reliable
reports that she never knew her grandparents: “They died before I was
historian.
born”. Her parents were both only children. Her father died when she was
nine years old of a heart attack: “I don’t know his health history except he
drank alcohol daily and smoked cigarettes; I think that was damaging to hi
heart.” Her mother died " in her 90’s” from pancreatic cancer. Her mother
also had several strokes.
Personal/Social Hx:
Chief Complaint/RFE:
“I have had a dry cough” Mrs. C.W. reports she has been married for 42 years. She denies using
Hx Present Illness: (7 Variables
tobacco products, drinking alcohol, or using recreational drugs.
but do not list as such)
Mrs. C.W. reports that the onset of her cough was “3 or 4 days ago.” The location of her pain is “[my] chest and
throat” She describes the character of her cough as “irritating to me and to others”. Mrs. C.W. reports that her other
symptoms include coughing up phlegm; she also states, “I didn’t’ realize it, but I have a fever when I came in today.”
She reports her cough is aggravated in the morning--“just when [I] wake up”. She reports the cough is only relived “
the day goes on”. She denies having any contacts with people who might be sick. She rates the pain associated with
her cough at a 4 or 5 out of 10 on 0-10 scale. She reports taking cough drops to help relieve her cough.
CURRENT HEALTH
Medications:
Plaquenil 200 mg 1 tablet BID daily.
, SOAP 3
Drug: Hydroxychloroquine sulfate dosing for diagnosis of Systemic Lupus Erythematosus (SLE) 200-400
mg/day PO divided qd-bid. Max: 400 mg/day or 5 mg/kg/day using Autologous Whole Blood. Indication: This
medicine did have investigational use to treat COVID-19; FDA revoked that June, 15, 2020. Malaria prophylaxis and
treatment, SLE, and rheumatoid arthritis Class: Disease-modifying antirheumatic drug (DMARDs), Conventional;
and Malaria Action: exact mechanism of action unknown; interferes w/ parasitic vesicle functions and phospholipid
metabolism by increasing pH, interrupts plasmodial erythrocyte stages (antimalarial); inhibits rheumatoid factor, acu
phase reactants, and various enzymes (antirheumatic/immunosuppressive). Common & Major S/E: Common:
dizziness, ataxia, headache, abdominal pain, nausea, vomiting, diarrhea, pruritus, weight loss, hair bleaching,
photosensitivity, tinnitus, vision changes and Major: agranulocytosis, thrombocytopenia, aplastic anemia, leukopenia
seizures, angioedema, bronchospasm, exfoliative dermatitis, Stevens-Johnson syndrome drug reaction w/ eosinophili
and systemic surgery, toxic epidermal necrolysis, psoriasis exacerbation, porphyria exacerbation, retinal damage
(high-dose or long-term use), retinopathy (high-dose or long-term use), macular degeneration (high-dose or long-term
use), myopathy, fulminant hepatic failure, cardiomyopathy, ventricular arrhythmia, QT prolongation, Torsade’s de
pointes, suicidality, hypoglycemia. Patient Education: Instructed Mrs. C.W. to take this medication with a meal or
glass of milk unless her doctor has told her otherwise. Informed Mrs. C.W. that, to treat lupus or arthritis,
hydroxychloroquine is usually taken daily and that she should call her doctor for instructions if she misses a dose.
Reminded Mrs. C. W. that this medication can have a dangerous effect on her heart, especially if she is also
using certain other medicines. Instructed her to seek emergency medical attention if she experiences fast or pounding
heartbeats and sudden dizziness (as if she might pass out) (Epocrates Online, 2020c.).
Restasis ophthalmic drops 0.05% 1 gtt in bilateral eyes q12h.
Drug: Cyclosporine ophthalmic suspension 0.05% 1 gtt in eye(s) q12h. Indication: Ocular dryness,
inflammation-associated. Class: Ocular dryness/Irritation. Action: exact mechanism of action unknown; acts as a
Module 2: Comprehensive SOAP Note
Katherine A. Wilcoxson
University of Texas at Arlington
In partial fulfillment of the requirements of
NURS 5120-436 Adult-Gerontology Assessment
Course Faculty: Jennifer Robb, MSN, ANCP, ANCC
March 3, 2021
, SOAP 2
SOAP Note Form
S/ Identifying Information: (initials, Family Hx:
age/DOB, gender, reliability)
This is Mrs. C.W., a 64-year-old
Mrs. C.W. was an only child; her parents are both decreased. She
Caucasian female. She is a reliable
reports that she never knew her grandparents: “They died before I was
historian.
born”. Her parents were both only children. Her father died when she was
nine years old of a heart attack: “I don’t know his health history except he
drank alcohol daily and smoked cigarettes; I think that was damaging to hi
heart.” Her mother died " in her 90’s” from pancreatic cancer. Her mother
also had several strokes.
Personal/Social Hx:
Chief Complaint/RFE:
“I have had a dry cough” Mrs. C.W. reports she has been married for 42 years. She denies using
Hx Present Illness: (7 Variables
tobacco products, drinking alcohol, or using recreational drugs.
but do not list as such)
Mrs. C.W. reports that the onset of her cough was “3 or 4 days ago.” The location of her pain is “[my] chest and
throat” She describes the character of her cough as “irritating to me and to others”. Mrs. C.W. reports that her other
symptoms include coughing up phlegm; she also states, “I didn’t’ realize it, but I have a fever when I came in today.”
She reports her cough is aggravated in the morning--“just when [I] wake up”. She reports the cough is only relived “
the day goes on”. She denies having any contacts with people who might be sick. She rates the pain associated with
her cough at a 4 or 5 out of 10 on 0-10 scale. She reports taking cough drops to help relieve her cough.
CURRENT HEALTH
Medications:
Plaquenil 200 mg 1 tablet BID daily.
, SOAP 3
Drug: Hydroxychloroquine sulfate dosing for diagnosis of Systemic Lupus Erythematosus (SLE) 200-400
mg/day PO divided qd-bid. Max: 400 mg/day or 5 mg/kg/day using Autologous Whole Blood. Indication: This
medicine did have investigational use to treat COVID-19; FDA revoked that June, 15, 2020. Malaria prophylaxis and
treatment, SLE, and rheumatoid arthritis Class: Disease-modifying antirheumatic drug (DMARDs), Conventional;
and Malaria Action: exact mechanism of action unknown; interferes w/ parasitic vesicle functions and phospholipid
metabolism by increasing pH, interrupts plasmodial erythrocyte stages (antimalarial); inhibits rheumatoid factor, acu
phase reactants, and various enzymes (antirheumatic/immunosuppressive). Common & Major S/E: Common:
dizziness, ataxia, headache, abdominal pain, nausea, vomiting, diarrhea, pruritus, weight loss, hair bleaching,
photosensitivity, tinnitus, vision changes and Major: agranulocytosis, thrombocytopenia, aplastic anemia, leukopenia
seizures, angioedema, bronchospasm, exfoliative dermatitis, Stevens-Johnson syndrome drug reaction w/ eosinophili
and systemic surgery, toxic epidermal necrolysis, psoriasis exacerbation, porphyria exacerbation, retinal damage
(high-dose or long-term use), retinopathy (high-dose or long-term use), macular degeneration (high-dose or long-term
use), myopathy, fulminant hepatic failure, cardiomyopathy, ventricular arrhythmia, QT prolongation, Torsade’s de
pointes, suicidality, hypoglycemia. Patient Education: Instructed Mrs. C.W. to take this medication with a meal or
glass of milk unless her doctor has told her otherwise. Informed Mrs. C.W. that, to treat lupus or arthritis,
hydroxychloroquine is usually taken daily and that she should call her doctor for instructions if she misses a dose.
Reminded Mrs. C. W. that this medication can have a dangerous effect on her heart, especially if she is also
using certain other medicines. Instructed her to seek emergency medical attention if she experiences fast or pounding
heartbeats and sudden dizziness (as if she might pass out) (Epocrates Online, 2020c.).
Restasis ophthalmic drops 0.05% 1 gtt in bilateral eyes q12h.
Drug: Cyclosporine ophthalmic suspension 0.05% 1 gtt in eye(s) q12h. Indication: Ocular dryness,
inflammation-associated. Class: Ocular dryness/Irritation. Action: exact mechanism of action unknown; acts as a
