PVD SOAP Chief complaint: bilateral leg edema 67-year-old African American

PVD SOAP Chief complaint: bilateral leg edema 67-year-old African American female Past medical history: HTN, T2DM, OA Past surgical history: cholecystectomy requiring blood transfusion approximately 35 years ago Denies any shortness of breath or chest pain Symptoms began approximately 4 weeks ago, increasingly becoming worse. Now not able to wear her normal shoes. She has also noticed significant indentation around her ankles. Lives alone, former smoker Vital signs: BP 100/60 HR 86 RR 16 SA 02 98% T 98.9 Bilateral lower leg edema 2+ Lung sounds clear bilaterally Normal S1 and S2, no murmurs, rubs or gallops admits to dark colored urine for the past week, denies any other urinary symptoms admits to feeling tired or weak for the past 2 weeks. Medications: HCTZ 25 mg QD, Metformin 1 gm BID, Ibuprofen 600 (as needed), Pioglitazone 30 mg QD Abdomen is soft and nontender, liver is palpable below costal margin, spleen is palpable Bilateral sclera is anicteric, JVP normal Denies any heart or kidney disease. admits to generalized pruritis but denies rash Denies any history of alcohol use Spiritual history: Catholic, not currently attending Mass, prays rosary at home every evening Write a history of present illness paragraph with this information

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