CONPH NSG6320/NSG6420 Subjective, Objective, Assessment, Plan (SOAP) Notes

CONPH NSG6320/NSG6420 Subjective, Objective, Assessment, Plan (SOAP) Notes
Student Name: Edgar C. Harvey Jr. Course: NSG 6420
Patient Name: S.J Date: 7/30/24 Time: 0916
Ethnicity: Hispanic Age: 68 Sex Female
SUBJECTIVE (must complete this section)
CC: swelling and pain to client right leg
HPI: The patient presents to the clinic feeling much pain and swelling in her right leg for the past five
days. The leg is swollen, resulting in changes in the color of the right leg to reddish. She reports chest
pain, which worsens whenever she takes a deep breath. Consequently, she experiences rapid breathing
whenever she takes a deep breath. On a scale of 1 to 10, the patient rates the pain as 7/10. She reports
having taken diclofenac to relieve the pain in vain. The patient reports that the pain aggravates when she
keeps standing for long hours and does not seem to go always any time soon. Pt. reports to have smoked
tobacco and stopped it one year ago. She denies any history of licit drugs, hospitalization, or surgeries.
Pt. reports a history of congestive heart failure in her late mother and hypertension, which claimed the
life of her father 2 years ago. She denies any past diagnosis or surgery related to cancer. She reports
retiring as a telecommunications oHicer, and her current state of health is very demanding, especially
regarding her time and resources. She admits to rarely undertaking physical exercise.
Medications: Diclofenac
Previous Medical History:
Allergies: none
Medication Intolerance: none
Chronic Illnesses/Major traumas: none
Hospitalizations/Surgeries: none
FAMILY HISTORY (must complete this section)
M: died from high blood pressure
MGM: died old age
MGF: died of cancer
F: died from CHF
PGM: unknown 

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