NR 509 Week 1 Health History SOAP Note

Document Content and Description Below

SOAP Note Template Initials: TJ Age: 28 Gender: Female Height Weight BP HR RR Temp SPO2 Pain Allergies 170cm 90kg 142/ 82 86 19 101.1 F 99% Medication: Penicillin (hives, rash) Food: none Env... ironment: Cats (asthma flare up, sneezing, itchy eyes) History of Present Illness (HPI) Chief Complaint (CC) Infected right foot wound 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 1week ago Location Right foot on the bottom Duration 1 week and few days Characteristics Swollen near the scrape, open, red, and painful but worse when walking on it. Aggravating Factors Walking. movement Relieving Factors Resting and pain medications Treatment Tramadol 50mg PO 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 Ibuprofen 200mg Q 6 hrs PRN PRN PRN for menstrual pain. Proventil 90mcg 2 puffs TID PRN PRN since childhood PRN asthma symptoms. Tramadol 50mg PRN every 8 hrs PRN PRN for wound pain in right foot. 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. 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. 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 This study source was downloaded by 100000831988016 from CourseHero.com on 05-01-2022 08:04:37 GMT -05:00 Asthma, Diabetes, no hx of surgeries, last hospital admission as a child for asthma exacerbation. Immunization status up to date. Last Tetanus : 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. Manager for , Student to study accounting, close with mother and sister (living together), Brother lives elsewhere, father deceased from car accident. Denies tobacco use. Alcohol use socially with friends ( rum and diet coke). Drives and uses 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)- T2DM, high cholesterol and hypertension. Brother 25 y.o.- Obesity Sister 14 y.o -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 states is tired recently. ☐Weakness denies ☒Fever/Chills 101.1F ☒Weight Gain 90kg currently ☐Weight Loss denies ☐Trouble Sleeping denies ☐Night Sweats denies ☐Other: Click or tap here to enter text. ☐Itching denies ☐Rashes denies ☐Nail Changes denies ☒Skin Color Changes Stated has had the skin discoloration on neck is chronic ☒Other: Right foot wound from scrape, possible infection and reports pain. ☐Diplopia denies ☐Eye Pain denies ☐Eye redness denies ☐Vision changes denies ☐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. This study source was downloaded by 100000831988016 from CourseHero.com on 05-01-2022 08:04:37 GMT -05:00 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 ocassionally- not currently ☐Numbness denies ☐Tingling denies ☐Sensation Changes ☐Speech Deficits denies ☐Other: Click or tap here to enter text. ☐Chest pain denies ☐SOB denies ☐Exercise Intolerance denies ☐Orthopnea denies ☒Edema swollen right foot near wound ☐Murmurs denies ☐Palpitations normal ☐Faintness denies ☐OC Changes denies ☐Claudications denies ☐PND denies ☐Other: Click or tap here to enter text. MSK GI GU PSYCH ☒Pain Pain in right foot from wound ☐Stiffness denies ☐Crepitus denies ☒Swelling Right foot near wound ☒Limited ROM ☒Redness on Right foot wound ☐Misalignment denies ☐Other: Click or tap here to enter text. ☐Nausea/Vomiting denies ☐Dysphasia denies ☐Diarrhea denies ☐Appetite Change denies ☐Heartburn denies ☐Blood in Stool denies ☐Abdominal Pain denies ☐Excessive Flatus denies ☐Food Intolerance denies ☐Rectal Bleeding denies ☐Other: Click or tap here to enter text. ☐Urgency denies ☐Dysuria denies ☐Burning denies ☐Hematuria denies ☐Polyuria denies ☐Nocturia denies ☐Incontinence denies ☐Other: Click or tap here to enter text. ☒Stress occasionally- denies severe stress. ☐Anxiety denies ☐Depression denies ☐Suicidal/Homicidal Ideation denies ☐Memory Deficits denies ☐Mood Changes denies ☐Trouble Concentrating denies ☐Other: Click or tap here to enter text. GYN ☐Rash denies ☐Discharge denies ☐Itching denies ☒Irregular Menses Reports 6 periods in a year ☒Dysmenorrhea Painful menstrual cycles ☐Foul Odor denies ☒Amenorrhea reports only 6 periods per year. ☒LMP: last month ☐Contraception denies current use ☐Other:Click or tap here to enter text. O: Objective Information gathered during the physical examination by inspection, palpation, auscultation, and palpation. If unable to assess a body system, write “Unable to assess”. Document pertinent positive and negative assessment findings. This study source was downloaded by 100000831988016 from CourseHero.com on 05-01-2022 08:04:37 GMT -05:00 This study source was downloaded by 100000831988016 from CourseHero.com on 05-01-2022 08:04:37 GMT -05:00 Body System Positive Findings Negative Findings General Neck discoloration. Right foot wound Click or tap here to enter text. Skin Neck discoloration chronic, right foot wound Click or tap here to enter text. HEENT Click or tap here to enter text. WNL Respiratory HX of Asthma WNL Neuro Click or tap here to enter text. WNL Cardiovascular Hx HTN WNL Musculoskeletal Right foot pain worse when bearing weight to right foot. Click or tap here to enter text. Gastrointestinal Click or tap here to enter text. WNL Genitourinary Click or tap here to enter text. WNL Psychiatric Click or tap here to enter text. WNL This study source was downloaded by 100000831988016 from CourseHero.com on 05-01-2022 08:04:37 GMT -05:00 Problem List 1. Pain-Right foot wound 6 irregular painful menstrual cycles 11 Click or tap here to enter text. 2 Wound infection 7 Click or tap [Show More]

Last updated: 1 year ago

Preview 1 out of 8 pages