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SOAP note for practice

created Dec 10th 2017, 18:49 by AddieHancock


3


Rating

326 words
15 completed
00:00
cc: right hip pain
HPI: this 63y/o african american female who looks much younger thn her stated age presents to the office w/ a c/o right hip pain. Pain is located on the lateral aspect greater trochanter and does not radiate. Pain has occured on and off over the past 2 months after a fall. She states that she didnt see an area rug turned up and tripped. Pain is worse with walking and improves when she is at rest. Pain is decribed as a dull ache but sometimes sharp with a change in movement. Denies numbness or tingling in leg  or weakness when she walks. Denies bowel/bladder incontinence. Typically lasts 20 mins but never completely goes away. Pain is a 2-7/10 on a pain scale.  
 
PMH: childhood illness - chickenpox Adult: HTN G0P0 LNP was 3 weeks light flow 3-5 dyas  Health screeneing: UTD on mammograms, papsemars. Gets annual flu shot and last one  2 wks ago.
 Surgeries- tonsilectomy age 12  no blood transfusions and no complications
 
FH : F is  decreased age 92 from an MI lasts yr.  M: alive with HTN age 82. Brother and sister are alive and healthy
 
SH: ADLs still does house cleaning and can get around well. She is finding it difficult to keep up cleaning due to her hip pain lifestyle habits walks for an hour everyday. Denies tobacco alcohol or illicit drug use but did drink socially when she was young.
 
Meds: daily MVI. Lisinopril 10 mg po 2x daily
 
Allergies: alleriges to sulfa drugs- hives no other allergies to  latex, foods or environment  
 
ROS: C: no wt. loss no fevers no chills
Eyes; no blurred vision or vision loss
Card:no chest pains or heart palpatiations
Resp: no shortness of breath no cough
MSK ; no swelling or joint pain other than the r ight hip pain see HPI  
Neuro: no numbness, no tingling and no weakness in the arms or legs
Heme: no brusing or bleeding  
 
 

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