Chamberlain College of NursingNR 509NR509- week 6_SOAP

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nitials: D.R. Age: 8 Gender: male Height Weight BP HR RR Temp SPO2 Pain Allergies 4’2 90lbs per patient( unable to get a standin g weight. 120/ 76 100 28 37.2c 96% Medication: Denies Fo... od: Denies Environment: Denies History of Present Illness (HPI) Chief Complaint (CC) Cough CC is a BRIEF statement identifying why the patient is here - in the patient’s own words - for instance "headache", NOT "bad headache for 3 days”. Sometimes a patient has more than one complaint. For example: If the patient presents with cough and sore throat, identify which is the CC and which may be an associated symptom Onset Cough started 5 days ago Location throat Duration Coughing every few minutes lasting 1-2min , for the past five days. Characteristics Productive cough rated a 5 out of 10 with clear and thin sputum, cough worsens at night. Associated symptoms of sore throat and earache,(gargly and watery associated with sore throat) Aggravating Factors Worse at night. Reports cough stays the same no matter what I do. (cough at night think CHF, GERD, Asthma…) Relieving Factors Cough medicine “helped a little” Treatment resting Current Medications: Include dosage, frequency, length of time used and reason for use; also include OTC or homeopathic products. Medication (Rx, OTC, or Homeopathic) Dosage Frequency Length of Time Used Reason for Use Gummy multivitamin 2-4 gummies daily Unable to answer my question when asked. “to stay healthy” Cough medicine “ a spoonful” One time “Once this AM” Cough N/A Click or tap here to Click or tap here to enter Click or tap here Click or tap here to enter text. S: Subjective Information the patient or patient representative told you This study source was downloaded by 100000831446146 from CourseHero.com on 09-11-2021 04:05:46 GMT -05:00 This study resource was shared via CourseHero.comenter text. text. to enter text. N/A Click or tap here to enter text. Click or tap here to enter text. Click or tap here to enter text. Click or tap here to enter text. N/A Click or tap here to enter text. Click or tap here to enter text. Click or tap here to enter text. Click or tap here to enter text. Past Medical History (PMHx) – Includes but not limited to immunization status (note date of last tetanus for all adults), past major illnesses, hospitalizations, and surgeries. Depending on the CC, more info may be needed. -Reports frequent colds and Rhinorrhea. Reports no fever last few times mother checked temperature. Hx of frequent earaches at 2 yrs old. -Pneumonia last year at 7 years old, missed school for 2 weeks, treated at an urgent care with unknown antibiotics (can’t recall the name). -Hearing checked 1 month ago at school: reports it was normal. -Last dental visit 2 months ago: reports no cavities. -Denies any previous surgeries. Stated has tonsils still and no ear surgeries. Denies prior hospitalizations. According to patient chart immunizations up to date at this time. No influenza vaccine, last 12 months. Social History (Soc Hx) - Includes but not limited to occupation and major hobbies, family status, tobacco a [Show More]

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