NR 509 Week 3 Neurology SOAP Note (version 1) 2019/2020, complete template solutions.

Document Content and Description Below

SOAP Note Template Initials: TJ Age: 28 Gender: Female Height Weight BP HR RR Temp SPO2 Pain Allergies 170cm 88kg 139/ 87 82 16 98.9F 99% Medication: Penicillin (rash/ hives) Food: none Env... ironment: Cats, dust (asthma flares up, itchy, watery eyes, sneezing) History of Present Illness (HPI) Chief Complaint (CC) Headache 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 5 days ago Location Pain is located at the crown and back of head. Duration Intermittent- daily-lasts for 1-2hrs per episode. Characteristics Dull headache, non- radiating, associated with neck pain Aggravating Factors Movement of head Relieving Factors Tylenol- improved pain to 3/10 ,rest Treatment No other treatment 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 Proventil 2 puffs PRN for asthma PRN Rescue inhaler for asthma exacerbation Flovent Patient unaware of exact dosage BID Daily Mainenence for Asthma Tylenol 2- regular strength tabs Once a day Once a day for 5 days For headache Advil 200mg PRN PRN For menstrual cramps 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. S: Subjective Information the patient or patient representative told you Should include: the accident MVA, should pertain to the Chief complaint, 15mile accident in parking lot, wearing seat belt, rear end fender bender. Was not drinking alcohol. (Asthma dx age 2.5 yrs old, Diabetes dx at 24yrs old, Denies surgical history, last hospital admission at 16 yrs old for asthma exacerbation. Reports all Immunization are current at this visit, Last Flu vaccine: 5 or 6 years ago per patient, declines at this time Last Tetanus booster: two years ago Reports Meningitis Vaccine at 19yrs old. Social History (Soc Hx) - Includes but not limited to occupation and major hobbies, family status, tobacco and alcohol use, and any other pertinent data. Include health promotion such as use seat belts all the time or working smoke detectors in the house. Supervisor at Mid-American Copy & Ship, Bachelor’s accounting student, Hobbies:Reading, watchingTV, hanging with friends and going to church. Close with mother and sister (living together), Brother lives with fiancee, father deceased from car accident. Denies tobacco use. Alcohol use socially with friends ( rum and diet coke drink of choice). Drives and always uses a seatbelt, working smoke detector in house. Family History (Fam Hx) - Includes but not limited to illnesses with possible genetic predisposition, contagious or chronic illnesses. Reason for death of any deceased first degree relatives should be included. Include parents, grandparents, siblings, and children. Include grandchildren if pertinent. Mother- high cholesterol and hypertension Father (deceased at 58 car accident 2 years ago)- Hx of Diabetes, high cholesterol and hypertension Brother 25 y.o.- Obesity Sister 14 yrs old- dx age 2 or 3 with asthma. maternal grandma- HTN and high cholesterol maternal grandpa-HTN and high cholesterol. paternal grandma-HTN and high cholesterol paternal grandpa- (deceased) colon cancer, HTN, diabetes. Review of Systems (ROS): Address all body systems that may help rule in or out a differential diagnosis Check the box next to each positive symptom and provide additional details. Constitutional Skin HEENT ☐Fatigue Denies ☐Weakness Denies ☐Fever/Chills Denies ☐Weight Gain Denies ☐Weight Loss Denies ☐Trouble Sleeping Denies ☐Night Sweats Denies ☐Other: ☐Itching Denies ☐Rashes Denies ☐Nail Changes Denies ☐Skin Color Changes Denies ☐Other: Click or tap here to enter text. ☐Diplopia Denies ☐Eye Pain Denies ☐Eye redness Denies ☒Vision changes blurry when does a lot of reading ☐Photophobia Denies ☐Eye discharge Denies ☐Earache Denies ☐Tinnitus Denies ☐Epistaxis Denies ☐Vertigo Denies ☐Hearing Changes Denies ☐Hoarseness Denies ☐Oral Ulcers Denies ☐Sore Throat Denies ☐Congestion Denies ☐Rhinorrhea Denies ☐Other: Click or tap here to enter text. Click or tap here to enter text. Respiratory Neuro Cardiovascular ☐Cough denies ☐Hemoptysis denies ☐Dyspnea denies ☐Wheezing denies ☐Pain on Inspiration denies ☐Sputum Production ☐Other: Click or tap here to enter text. ☐Syncope or Lightheadedness denies ☒Headache reports tension ☐Numbness denies ☐Tingling denies ☒Sensation Changes ☐Speech Deficits denies ☒Other: denies sensation changes ☐Chest pain denies ☐SOB denies ☐Exercise Intolerance denies ☐Orthopnea denies ☐Edema unable to assess ☐Murmurs unable to assess ☐Palpitations unable to assess ☐Faintness unable to assess ☐OC Changes denies ☐Claudications denies ☐PND denies ☐Other: Click or [Show More]

Last updated: 1 year ago

Preview 1 out of 8 pages