SOAP Note – 5

Nikki Tacsik
12/7/20
NURS7029 Practicum

Subjective:
Chief Complaint: 74-year-old African American male seen in the nursing facility on 12/3/20
with chief complaint of lower extremity swelling bilaterally
History of Present Illness: Patient presents with swelling in his lower extremities bilaterally.
Patient states the swelling started about a week ago and has progressively gotten worse. He
states the only swelling is in his lower extremities. He states he can feel that his legs are
swollen because they feel tight and heavy. Nothing makes it worse, but he has noticed they
are better in the morning after laying in bed all night. He states this has happened before
when he has a heart failure flare up. He denies any other symptoms such as shortness of
breath, chest pain, night sweats, chills, or fevers.
General Medical History:
Medical: high cholesterol (10 years ago), hypertension (10 years ago), arthritis (20 years
ago), heart failure (7 years ago)
Surgical: gallbladder removed in 1990, bilat knee replacement in 2003
Medications: Lipitor 40 mg PO nightly, Prilosec 20 mg PO daily, Norvasc 10 mg daily,
metoprolol 25 mg bid, lasix 20 mg daily, potassium chloride 20 mEq daily, advil PRN for
arthritis pain – has not taken it in a while, senna-kot daily, colace daily,
Allergies: penicillins – unknown, lisinopril – palpitations, betapace – dizziness
Family History: Patient’s grand parents’ history is unknown. Patient’s mother is deceased
due to a heart attack. Patient’s dad is deceased due to heart disease also. Patient has 2 siblings
– but family history is unknown. Patient has 2 kids. One with no significant medical history
and the other with asthma.
Social History: Patient is widowed and lives in a nursing home facility. Is independent with
ADLs with a walker and enjoys going out with his kids when possible. COVID has kept him
confined to the nursing home but he enjoys the activities at the facility. Denies any current
nicotine use, alcohol use, or illicit drug use. Denies any thoughts of suicide or abuse. Former
smoker 1 PPD x 20 years. Denies any recent travel or known sick contacts.
Review of Systems:
General Constitutional: Denies change in appetite, fever, chills, night sweats, weight gain or
loss.
EENT: Pt wears reading glasses. Denies recent change in vision, discharge from eyes or ears,
earaches, problems swallowing, or sore throat.
Skin: Denies any changes in skin texture or new lesions. Denies new moles, pruritis, or
rashes.
Respiratory: Denies shortness of breath, cough, hemoptysis, wheezing, or sleep apnea.
Cardiovascular: Positive for edema in bilateral lower extremities. Denies chest pain,
palpitations, or orthopnea.
Gastrointestinal: Denies bloating, abdominal pain, constipation, nausea, or vomiting. Bowel
habits are normal for patient.
Genitourinary: Denies pain with voiding, frequency, foul smelling urine, or urgency.
Endocrine: Denies or cold intolerance, excess hair loss or growth, hypoglycemia,
hyperglycemia, or dry skin.
Neurologic: Denies dizziness, seizures, syncope, vertigo, or weakness.
Mental Health: Denies anxiety, depression, abuse, or suicidal ideation.

Objective:
Weight: 195 lbs Height: 6 ft BMI: 27 (overweight)
Vital Signs: BP 152/88, HR 72, RR 18, temp 98.6 orally, SpO2 96% on room air
Constitutional: Well appearing pleasant 74-year-old Caucasian male. Patient is dressed
appropriately for weather and is well groomed. Clothes are slightly tattered but clean.
Cooperative, speech is appropriate for developmental age and situation. Seems to be a decent
historian but not the best.
HEENT: Normocephalic and symmetrical head. Trachea midline. No missing teeth, gums
appear pink and moist.
Skin: Skin even tone and appropriate for ethnicity. No rashes, lesions, or masses from what is
observed.
Respiratory: Respirations unlabored. Respiratory rate regular. Respirations normal depth.
Breath sounds clear in bilateral lobes.
Cardiac: S1 and S2 heard. No murmurs or gallops. HR regular.
Abdomen: Abdomen rounded and without masses on inspection. Bowel sounds active in all 4
quadrants. Abdomen soft and nontender on palpation.
Musculoskeletal: Gait unsteady but uses a walker and strength equal bilaterally.
Neurological: Alert and oriented x4. Communicates appropriately with appropriate mood and
affect. Forgetful at times.
Assessment:
Patient presents with bilateral lower extremity edema x1 week. Denies any other symptoms.
Patient has a history of CHF and this is most likely an exacderbation.
Differential Diagnosis:
1. CHF exacerbation**
2. DVT
3. Liver failure
4. Venous insufficiency
Plan:
Patient assessed in the office and patient is felt to be a decent historian. Will obtain CBC,
CMP, and BNP blood work among a liver panel to rule out liver insufficiency. Since the
patient denies any respiratory or “cardiac” symptoms will hold off on a CXR for now. Will
also hold off on US BLE until follow up since the patient denies pain and it is unusual to
have bilat DVTs. BNP will also be obtained to assess for CHF. Will increase the patient’s
Lasix and follow up in a week. If shortness of breath or chest pain occurs among other new or
worsening symptoms will send pt to ER for IV diuretics and further testing. If symptoms
don’t improve but not new symptoms occur will obtain BLE US and CXR.
Diagnostic Testing:
Lab work – pending
Treatment:
Increased pt’s original order of 20 mg Lasix daily PO to 40 mg Lasix bid PO x 1 week. Also
increased potassium chloride to 40 mEq daily a week. Strict intake and output was ordered
for the nursing staff to record. TED hose were also ordered for the pt to wear during the day
and remove at night. A low salt diet was further educated to the patient to abide by. Instructed
the patient to be aware of worsening or new symptoms and to instruct nursing staff if they
occur. Will follow up in 1 week with patient.