Have a question?
Message sent Close

NURS 3175 Example+Complete+SOAP+(3)

John Marsh
0 reviews
  • Description
  • Full Document


Columbus State University

Pharmacology In Nursing (NURS 3175)

Chief Complaint: “I’ve been nauseous and throwing up for a few days. I’ve been cramping and
haven’t been able to keep anything down. This isn’t the first time this has happen.”
History of Present Illness: 39 year old African American female presents with complaints of
nausea, vomiting, and diffuse abdominal cramps for the last 2 days. The patient rated the pain
level 7 out of 10, 10 being the most intense and in the epigastric region. The patient states that
food is an aggregating agent so she has been alleviating the vomiting herself by restricting her
intake. She states she has vomited several times within the past few days. The nausea and
cramping are consistent symptoms without any alleviation. The patient denies any diarrhea.
Past Medical History:
 End Stage Renal Disease- 585.6
 Systemic Lupus Erythematosus- 710.0
 Obesity- 278.0
 Hypertension- 401.9
 Anemia- 285.9
 Esophageal Ulcers- 530.2
 Gastric Ulcers- 531.90
 LMP: January 19, 2015
 OB/GYN: Denies any abnormalities in last pap smear.
 Surgical Hx:
o AVF in left leg 2012 Midtown Medical Center.
o Parathyroidectomy 2011 Midtown Medical Center.
Current Health Status:
1. Allergies: Codeine phosphate, Ondansetron HCl, Codeine, and Penicillin
2. Tobacco: Denies use
3. ETOH: Denies use
4. Illegal drugs: Denies use.
5. Current meds:
 Calcitriol (Rocaltrol) 0.5 mcg capsule; 1 tablet PO daily for calcium replacement
 Aspirin (Baby Aspirin) 81 mg chewable tablet; 1 tablet PO daily
 Amlodipine (Norvasc) 5 mg tablet; 1 tablet PO daily for hypertension
 Levetiacetam (Keppra) 500mg tablet; 1 tablet PO Tuesday, Thursday, and Saturday



NURS 3175 Example+Complete+SOAP+(3)

NOTE: Please check the details before purchasing the document.