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NURS 6540: Advanced Practice Care of Elders
Comprehensive SOAP Note Template
Patient Initials: DK Age: 55 Gender: Male
SUBJECTIVE DATA:
Chief Complaint (CC): I feel light headed
History of Present Illness (HPI): DK is a 57-year-old Caucasian male who is currently
receiving care at the skilled nursing facility following an acute hemorrhagic stroke of the
left basal ganglia and thalamus resulting in right hemiplegia. The patient was examined
today for staff concerns of hypotension and light-headedness. The patient was
participating in scheduled physical therapy when he verbalized to the staff he felt light-
headed. A blood pressure was obtained by therapy staff reading 86/43. The patients
therapy was stopped, and he was placed in a recliner. The patient denied dizziness
associated with his light-headedness, chest pain or shortness of breath. A repeat blood
pressure was obtained which read 110/83. A pulse ox was also obtained which read 98%
on room air. He states that he felt better sitting in the chair and the light-headiness was
subsiding. He was returned back to bed due to the hypotensive episode.
Medications:
Albuterol 2.5mg/3ml nebulizer solution Q6H PRN
Ventolin HFA 108 mcg/act 2 puffs Q4H PRN
Lipitor 40 mg Tablet Daily
Dulcolax 10 mg suppository rectally daily
Bumex 0.5 mg Tablet Daily
Coreg 25 mg Tablet BID – hold for SBP <100 or HR<60
Cardizem 30 mg Tablet Q8H – hold for SBP <100 or HR <60
Colace 100 mg Capsule Daily
Lexapro 5 mg Tablet Daily
Allegra 180 mg Tablet Daily
Imdur 60 mg Tablet Daily – hold for SBP <100 or HR <60
Prevacid Solutab 30 mg disintegrating Tablet every morning before breakfast
Keppra 100mg/ml solution – take 5 ml BID
Lisinopril 20 mg Tablet Daily – hold if SBP <100 or HR <60
Metformin 500 mg extended release tablet Daily
Dulera 100-5 mcg/act inhaler – 2 puffs BID
Singulair 10 mg tablet Q HS
Nitrostat 0.4 mg SL tablet – place 1 tablet under tongue every 5 minutes for chest
pain. Max of 3 doses
Ditropan 5 mg tablet Daily
Glycolax 17 g Daily PRN
© 2014 Laureate Education, Inc. Page 1 of 7
NURS 6540: Advanced Practice Care of Elders
Comprehensive SOAP Note Template
Patient Initials: DK Age: 55 Gender: Male
SUBJECTIVE DATA:
Chief Complaint (CC): I feel light headed
History of Present Illness (HPI): DK is a 57-year-old Caucasian male who is currently
receiving care at the skilled nursing facility following an acute hemorrhagic stroke of the
left basal ganglia and thalamus resulting in right hemiplegia. The patient was examined
today for staff concerns of hypotension and light-headedness. The patient was
participating in scheduled physical therapy when he verbalized to the staff he felt light-
headed. A blood pressure was obtained by therapy staff reading 86/43. The patients
therapy was stopped, and he was placed in a recliner. The patient denied dizziness
associated with his light-headedness, chest pain or shortness of breath. A repeat blood
pressure was obtained which read 110/83. A pulse ox was also obtained which read 98%
on room air. He states that he felt better sitting in the chair and the light-headiness was
subsiding. He was returned back to bed due to the hypotensive episode.
Medications:
Albuterol 2.5mg/3ml nebulizer solution Q6H PRN
Ventolin HFA 108 mcg/act 2 puffs Q4H PRN
Lipitor 40 mg Tablet Daily
Dulcolax 10 mg suppository rectally daily
Bumex 0.5 mg Tablet Daily
Coreg 25 mg Tablet BID – hold for SBP <100 or HR<60
Cardizem 30 mg Tablet Q8H – hold for SBP <100 or HR <60
Colace 100 mg Capsule Daily
Lexapro 5 mg Tablet Daily
Allegra 180 mg Tablet Daily
Imdur 60 mg Tablet Daily – hold for SBP <100 or HR <60
Prevacid Solutab 30 mg disintegrating Tablet every morning before breakfast
Keppra 100mg/ml solution – take 5 ml BID
Lisinopril 20 mg Tablet Daily – hold if SBP <100 or HR <60
Metformin 500 mg extended release tablet Daily
Dulera 100-5 mcg/act inhaler – 2 puffs BID
Singulair 10 mg tablet Q HS
Nitrostat 0.4 mg SL tablet – place 1 tablet under tongue every 5 minutes for chest
pain. Max of 3 doses
Ditropan 5 mg tablet Daily
Glycolax 17 g Daily PRN
© 2014 Laureate Education, Inc. Page 1 of 7
