Summary NR 509 Week 3 Neurology SOAP Note

Document Content and Description Below

SOAP Note Template Initials: T.J. Age: 28 years old Gender: Female Height Weight BP HR RR Temp SPO2 Pain Allergies 170cm 88kg 139/ 87 82 16 98.9 99% Medication: PCN (causes rash/hives) Food: Non... e Environment: Cats, Dust (causes asthma exacerbations) History of Present Illness (HPI) Chief Complaint (CC) Headaches with neck stiffness 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 Low speed car accident 1 week ago, symptoms began 2 days after accident Location Headache pain to crown and back of head Duration Every day lasting 1-2 hours Characteristics Headache pain is a dull ache Aggravating Factors Pain when moving neck Relieving Factors Rest and PRN Tylenol Treatment PRN Tylenol 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 Inhaler 90mcg 2 puffs as needed Every 4 hours as needed Wheezing, SOB Tylenol 650mg (takes 2 tablets) Once per day The past few days Heaches Advil 200mg TID PRN First 2 days of menstrual cycle Cramping Flovent Inhaler Click or tap here to enter text. Click or tap here to enter text. Click or tap here to enter text. Asthma 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, S: Subjective Information the patient or patient representative told you hospitalizations, and surgeries. Depending on the CC, more info may be needed. Diagnosed with DM at 24years old, noncompliant with metformin and checking blood sugar regularly, poor diet control Diagnosed with Asthma at 2.5years old, taking PRN inhaler for exacerbations, currently - PRN Inhaler is ineffective Heavy-flow periods with cramping, and breast tenderness. Pt has irregular periods (6 periods/year), lasting 9-10 days Immunizations current, received childhood vaccinations Flu shot received 5-6 years ago Last tetanus vaccine a year ago Pap-smear completed 4 years ago, normal No current eye exam, last time for an eye exam was when she was little Has not seen dentist in a few years, went twice a year as a child 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. Denies smoking and current recreational drug use, admits to smoking pot when 20-21 years old, pt stopped because it disturbed her asthma Pt is exposed to secondhand smoke occasionally Pt drinks occasionally, about 6 drinks per month. Currently working on bachelors degree for accounting Lives with mom and sister, family is a good support system Began sexual activity at age 18, has had 3 sexual partners (males), “sometimes” uses a condom 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 – HTN, Hypercholesterolemia Father – HTN, Type 2 DM, Hypercholesterolemia (deceseased d/t car accident) Paternal Grandfather – HTN, Diabetes, Colon Cancer (deceased from colon cancer) Paternal Grandmother – HTN, Hypercholesterolemia Maternal Grandfather – HTN, Hypercholesterolemia (deceased at 80 from Myocardial Infarction) Maternal Grandmother – HTN, Hypercholesterolemia (deceased at 73 from Stroke) Brother – Obesity Sister – Asthma Father and Dads Bother (Uncle) – Alcohol Addiction Father and Brother – Heavy set 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 – reports occasional blurry vision (prior to accident) when reading/studying for long periods of time ☐Photophobia Click or tap here to enter text. ☐Eye discharge Click or tap here to enter text. ☐Earache Click or tap here to enter text. ☐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 Click or tap here to enter text. ☐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 ☐Other: Click or tap here to enter ☐Syncope or Lightheadedness Click or tap here to enter text. ☒Headache – recently started 2 days after low speed car accident, occur every day for 1-2 hours, pain is a dull ache located in crown and back of head, denies pain radiating to another location. Reports past frequent headaches whe [Show More]

Last updated: 1 year ago

Preview 1 out of 11 pages