NR509 WEEK 4 SOAPNOTE

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NR509 WEEK 4 SOAPNOTE SOAP Note Template Initials: BF Age: 58 Gender: Male Height Weight BP HR RR Temp SPO2 Pain Allergies 5’ 11 197lbs 146/ 90 104 19 36.7C 98% Medication: Codeine : reports ... causes nausea and vomiting Food: none Environment: none History of Present Illness (HPI) Chief Complaint (CC) Chest pain 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 While doing strenuous acitivties, earlier this month. Location Middle of chest. Does not radiate. Duration 3 episodes for the past month. Each episode lasts for a couple of minutes. Characteristics Chest tightness in the middle of chest without radiation. Aggravating Factors Yard work and climbing stairs at work. Relieving Factors Taking a break or sat down to rest. Treatment Reports no treatment uses 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 Atorvastatin (Lipitor) PO 10mg Daily at HS One year High Cholesterol Metoprolol (Lopressor) PO 100mg Daily One year High blood pressure Omega-3 Fish Oil PO 1200mg Daily Unable to respond ( last dose taken this AM) Does not respond when asked why. Tylenol “Whatever the bottle recommends for an adult” PRN PRN For Headache Ibuprofen “Whatever the bottle recommends for an adult” PRN PRN Varioius aches and pains [Show More]

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