PRAC 6568 Week 8 Assignment I; Comprehensive SOAP Note

Week 8 Soap Note Prac: 6568 Walden University Samantha Johnson Patient Information: DF, 73 year old, Male, Caucasian (Patient # 118) S. CC: “Blood Pressure issues” HPI: DF is a 73-year-old Caucasian male patient who presented to the clinic today for Blood pressure issues. He reports his blood pressure has been running on the high side for the past month. He reports having a headache and occasional blurred vison. He rates his headache a 7/10 on the pain scale. He states taking Ibuprofen 600mg has helped ease the headache. He reports edema of lower extremities and shortness of breath with activity. He denies chest pain, pressure, or discomfort. He denies nausea and vomiting. Patient reports he is currently on Lisinopril, Amiodarone and Metoprolol for his blood pressure and was on Amlodipine till last month when he went to the emergency room and the doctor took him off it. He reports since then his blood pressure has been running high. Patient presented a Blood pressure log he has been keeping: 155/83 169/99 142/88 176/78 192/90 190/82 Current Medications: OTC Multivitamin for men: last dose last night at 8pm OTC Baby Aspirin 81mg, 1 Tablet once every day: Last dose this morning at 6am Furosemide 20mg 1 tablet every morning: Last dose this morning at 6am Lisinopril 10mg 1 tablet every morning: Last dose this morning at 6am Amiodarone 200mg, 1 tablet every morning: Last dose this morning at 6am Metoprolol 100mg 1 tablet BID: Last dose this morning at 6am Atorvastatin 40mg 1 tablet every night at bedtime: last dose last night at 8pm Omeprazole 40mg: 1 capsule every morning: Last dose this morning at 6am Potassium Chloride 10mg: 1 tablet once every other day: Last dose this morning at 6am Denies herbal supplements. Allergies: NKA PCN: Hives and swelling. Shrimp: Hives Denies Latex allergies. Denies environmental and seasonal allergies. PMHx: Patient reports she received all her child immunizations. Tdap 2019 Flu Vaccine: 2023 Covid Vaccines: 1st dose: Pfizer: 10/7/2021 2nd Dose: Pfizer 11/29/2021 Booster: Pfizer bivalent COVID-19: 10/14/2022 Denies any surgery history. Denies any hospitalizations. DM2 HTN Hyperlipidemia GERD CHF AFib Soc & Substance Hx: DF currently works full-time at a local factory that assembles semi-trucks. He currently lives with his significant other of 6 years. He enjoys reading books and magazines about guns, history, and cars. He enjoys going to drag races and dirt track races in his free time. He denies any alcohol use or illicit drug use. He is a current smoker of 10 years, smoking 1 to 2 packs a day. He reports occasionally vaping. DF reports he wears a seatbelt any time he is in a vehicle and denies texting and driving. He reports there are guns in his home but are all secure in a gin safe that is always locked. DF reports eating a balanced diet and starting to walk in the last month at least 3 days a week. Fam Hx: Son: Living 44years old: No significant medical history Son: Living 30