Chamberlain College of NursingNR 603wk 5 p 2

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Running head: WEEK 5 APEA PREDICTOR ASSIGNMENT Week 5 APEA Predictor Assignment Sara Martinez Chamberlain University NR 603: Advanced Clinical Diagnosis and Practice Across Life Span February 201... 9 2 WEEK 5 APEA PREDICTOR ASSIGNMENT SOAP NOTE Setting small rural clinic non-for-profit family practice that employs 2 LVN’S, 1 NP and 1 physician, and one onsite lab person to draw and run few lab tests and also can use the x-ray machine. Patient Information: DG 16-year-old male Hispanic, unknown (S) Subjective: Chief Complaint (CC): pain to foot History of Present illness: (HPI): DG is a 16-year-old Hispanic male who present to the clinic with father c/o left foot pain reporting that a 40 lb. dumbbell slipped out of his hand while lifting weights at the school gym x 2 days ago. Initially did not hurt but upon returning home from school after the workout it began to hurt describing the pain as throbbing to the left top of foot. Able to bear weight only complains of 3 out of 10 on the pain scale. Aggerating factors are weight bearing and unable to put on tennis show. Denies any ice, elevation or wrapping the extremity and the no additional medication for pain. Past Medical History (PMH): Allergies: NKDA Current medications: Multi vitamin and Father states OTC Tylenol 500 mg one given last night with minimal relief. Age/Health Status: 16 years/ No chronic health problems Appropriate immunization status: up to date on all vaccines including Flu shot 10/18 Dates of Illness: during childhood: none reported [Show More]

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