*NURSING > SOAP NOTE > NR 509 Week 7, Danny Rivera, SOAP Note, February 2020 (All)

NR 509 Week 7, Danny Rivera, SOAP Note, February 2020

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SOAP Note Template Initials: DR Age: 8 y/o Gender: M Height Weight BP HR RR Temp SPO2 Pain Allergies 4’2” 90 lbs 120/ 76 100 28 37.2 c 98.9 f 96 Medication: None Food: Click or tap here to... enter text. Environment: Click or tap here to enter text. History of Present Illness (HPI) Chief Complaint (CC) “I’ve been feeling sick, I’ve been coughing a lot, and I feel kind of tired”. 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 “The cough started five days ago” Location Chest Duration ”I just keep feeling like I have to cough every couple minutes or so.” Characteristics Cough is productive. Described as “gurgly and watery.” Sputum is clear. Aggravating Factors “My cough mostly stays the same no matter what I do. It seems to get worse at night though.” Relieving Factors OTC cough syrup provided some temporary relief of cough. “It helped a bit when my mom gave it to me, but my cough came back anyway.” Treatment OTC cough syrup. “I don't know what the name of the cough medicine is. It was purple.” 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 Multivitamin Gummy Unknown Daily Unknown “to be healthy” Purple Cough medicine (OTC) Small teaspoon This morning Unknown Cough 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. S: Subjective Information the patient or patient representative told you 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. No influenza vaccine in previous 12 months Hep A series completed at 15 months Heb B series completed at 6 months Pneumococcal series completed at 15 months DTap series completed at 6 yrs MMR series completed at 6 yrs Varicella series complete at 6 yrs Polio series completed at 6 yrs No surgical hx No prior hospitalizations Pneumonia last year (seen/treated in urgent care) 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. 3 rd grade student – missed 2 weeks of school d/t pneumonia Lives with both parents and grandmother English primary language; Spanish secondary 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: DM Type 2, HTN, hypercholesteremia, spinal stenosis, obesity Father: Smoker, HTN, hypercholesteremia, asthma as child Maternal Grandmother: DM Type 2, HTN Maternal Grandfather: Died in MVC (52 yo) Paternal Grandfather: No known hx 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 Click or tap here to enter text. ☐Weakness Click or tap here to enter text. ☐Fever/Chills Click or tap here to enter text. ☒Weight Gain Click or tap here to enter text. ☐Weight Loss Click or tap here to enter text. ☒Trouble Sleeping Click or tap here to enter text. ☐Night Sweats Click or tap here to enter text. ☐Other: Click or tap here to enter text. ☐Itching Click or tap here to enter text. ☐Rashes Click or tap here to enter text. ☐Nail Changes Click or tap here to enter text. ☐Skin Color Changes Click or tap here to enter text. ☐Other: Click or tap here to enter text. ☐Diplopia Click or tap here to enter text. ☐Eye Pain Click or tap here to enter text. ☐Eye redness Click or tap here to enter text. ☐Vision changes Click or tap here to enter text. ☐Photophobia Click or tap here to enter text. ☐Eye discharge Click or tap here to enter text. ☒Earache Right ear, started yesterday, 3/10, ☐Tinnitus Click or tap here to enter text. ☐Epistaxis Click or tap here to enter text. ☐Vertigo Click or tap here to enter text. ☐Hearing Changes Click or tap here to enter text. ☐Hoarseness Click or tap here to enter text. ☐Oral Ulcers Click or tap here to enter text. ☒Sore Throat 2/10 ☐Congestion Click or tap here to enter text. ☒Rhinorrhea Click or tap here to enter text. ☐Other: Click or tap here to enter text. Respiratory Neuro Cardiovascular ☒Cough Click or tap here to enter text. ☐Hemoptysis Click or tap here to enter text. ☐Dyspnea Click or tap here to enter text. ☐Wheezing Click or tap here to enter text. ☐Pain on Inspiration Click or tap here to enter text. ☒Sputum Production ☐Syncope or Lightheadedness Click or tap here to enter text. ☐Headache Click or tap here to enter text. ☐Numbness Click or tap here to enter text. ☐Tingling Click or tap here to enter text. ☐Sensation Changes ☐Speech Deficits Click or tap here to enter text. ☐Other: Click or tap here to ☐Chest pain Click or tap here to enter text. ☐SOB Click or tap here to enter text. ☐Exercise Intolerance Click or tap here to enter text. ☐Orthopnea Click or tap here to enter text. ☐Edema Click or tap here to enter text. ☐Murmurs Click or tap here to enter text. ☐Palpitations Click or tap here to enter text. ☐Faintness Click or tap here to enter text. ☐OC Changes Click or tap here to enter text. ☐Claudications Click or tap here to enter text. ☐PND Click or tap here to enter text. ☐Other: Click or tap here to enter text. ☐Other: Click or tap here to enter text. enter text. MSK GI GU PSYCH ☐Pain Click or tap here to enter text. ☐Stiffness Click or tap here to enter text. ☐Crepitus Click or tap here to enter text. ☐Swelling Click or tap here to enter text. ☐Limited ROM ☐Redness Click or tap here to enter text. ☐Misalignment Click or tap here to enter text. ☐Other: Click or tap here to enter text. ☐Nausea/Vomiting Click or tap here to enter text. ☐Dysphasia Click or tap here to enter text. ☐Diarrhea Click or tap here to enter text. ☐Appetite Change Click or tap here to enter text. ☐Heartburn Click or tap here to enter text. ☐Blood in Stool Click or tap here to enter text. ☐Abdominal Pain Click or tap here to enter text. ☐Excessive Flatus Click or tap here to enter text. ☐Food Intolerance Click or tap here to enter text. ☐Rectal Bleeding Click or tap here to enter text. ☐Other: Click or tap here to enter text. ☐Urgency Click or tap here to enter text. ☐Dysuria Click or tap here to enter text. ☐Burning Click or tap here to enter text. ☐Hematuria Click or tap here to enter text. ☐Polyuria Click or tap here to enter text. ☐Nocturia Click or tap here to enter text. ☐Incontinence Click or tap here to enter text. ☐Other: Click or tap here to enter text. ☐Stress Click or tap here to enter text. ☐Anxiety Click or tap here to enter text. ☐Depression Click or tap here to enter text. ☐Suicidal/Homicidal Ideation Click or tap here to enter text. ☐Memory Deficits Click or tap here to enter text. ☐Mood Changes Click or tap here to enter text. ☐Trouble Concentrating Click or tap here to enter text. ☐Other: Click or tap here to enter text. GYN ☐Rash Click or tap here to enter text. ☐Discharge Click or tap here to enter text. ☐Itching Click or tap here to enter text. ☐Irregular Menses Click or tap here to enter text. ☐Dysmenorrhea Click or tap here to enter text. ☐Foul Odor Click or tap here to enter text. ☐Amenorrhea Click or tap here to enter text. ☐LMP: Click or tap here to enter text. ☐Contraception Click or tap here to enter text. ☐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 systemwrite“Unabletoassess”Documentpertinentpositiveandnegativeassessmentfindings Body System Positive Findings Negative Findings General Danny appears to be unwell. Presents with persistent cough during assessment. This is a well-developed, pleasant, well nourished, in no apparent distress. Alert and Oriented x3, normal mood and affect, Ambulates without difficulty. Skin No pertinent findings Normal color with no rashes, no lesions, and no evidence of cellulitis. HEENT The right external auditory canal and tympanic membrane is erythemic. Nasal cavities has clear discharge. Tonsils is +2 erythemic; posterior pharynx is cobblestoning and erythemic Lymph node is palpable in right anterior cervical. [Show More]

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