COURSE  

NRNP 6540 Advanced Practice Care of Older Adults

Assessing, Diagnosing, and Treating Hematological and Immune System Disorders

Complete the Focused SOAP Note Template provided for the patient in the case study. See the Week 8 Assignment area for complete instructions.

By Day 7 Submit your Assignment

SOLUTION 

A.B. 68-year-old, Caucasian Female

SUBJECTIVE:

Chief Complaint: Feeling tired all the time and now, more recently, feeling weak and like “I can’t catch my breath sometimes.”

HPI: 68-year-old female presents to the office today for feeling weak lately and is unable to catch her breathe. Other than this complaint, the patient has been healthy except for high cholesterol. Patient attributes this weakness to dealing with the death of her husband nine months ago. Patient states she has been getting worse lately rather than getting better as time passes.

Allergies:                               NDA

Current Medications:           Lipitor 40mg daily

PMH:                                     High cholesterol

PSH:                                       Appendectomy in childhood; hysterectomy for uterine myoma 10 years ago.

ROS

General:                                 10-pound weight loss past 9 months

Cardiovascular:                    No chest pain

Respiratory:                         SOB

Gastrointestinal:                   No nausea

Genitourinary:                      Not listed

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