NURS 6531 SOAP NOTE NUMBER 1

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Week 3 Episodic SOAP Note #1 Patient Information: A.A., 20, Female, Caucasian S. CC: Sore throat, flu-like symptoms HPI: 20-year-old college student presents to office complaining of sore throat... , pain with swallowing, decreased appetite, headaches, runny nose and a slight hoarseness in her throat. Patient states her symptoms began approximately 3 days ago and denies any congestion in her voice. Patient admits that she is aware of flu-like symptoms have been “going around” at her campus. Current Medications: self-medicated with Tylenol for headaches as needed. Allergies: negative for any allergies to food and drugs PMHx: Updated immunization status for TDAP, Flu vaccine Soc Hx: Negative for tobacco abuse, alcohol consumption and use of illicit drugs. Patient is in college and a a heterosexual single female who dates casually and practices safe sex using birth control and condoms. Fam Hx: Mother is age 55 with no PMH and Father is age 57 who is a prostate cancer survivor. Patient denies diabetes, cardiovascular disease and stroke in her first-degree relatives. ROS: GENERAL: Positive for fatigue; negative for weakness, fever, no significant weight change. HEENT: Positive for headache, runny nose, hoarseness; negative for head injury, dizziness, lightheadedness, vision changes, hearing problems, tinnitus, vertigo, earaches, nosebleeds, sinus trouble, and dry mouth. SKIN: No rash or itching. CARDIOVASCULAR: No chest pain, chest pressure or chest discomfort. No palpitations or edema. RESPIRATORY: Negative for cough, sputum, hemoptysis, dyspnea, wheezing. This study source was downloaded by 100000805030033 from CourseHero.com on 08-12-2022 20:44:30 GMT -05:00 https://www.coursehero.com/file/41290876/NURS-6531-SOAP-NOTE-NUMBER-1docx/ GASTROINTESTINAL: Positive for difficulty swallowing, decreased appetite. Negative for heartburn, nausea, vomiting, diarrhea, rectal bleeding or tarry stools, constipation, abdominal pain, food intolerance. GENITOURINARY: Denies any GU issues. Last menstrual period, 03/01/2019. NEUROLOGICAL: No headache, dizziness, syncope, paralysis, ataxia, numbness or tingling in the extremities. No change in bowel or bladder control. MUSCULOSKELETAL: negative for muscle, back pain, joint pain or stiffness. HEMATOLOGIC: No history of anemia, bleeding or bruising. LYMPHATICS: No enlarged nodes. No history of splenectomy. PSYCHIATRIC: negative for depression or anxiety. ENDOCRINOLOGIC: negative for sweating, cold or heat intolerance. negative for polyuria or polydipsia. ALLERGIES: No history of asthma, hives, eczema or rhinitis. O. VS: BP 106/62; P 94; R 18; T 97.8; 02 99% Wt 118lbs; Ht 54” Physical exam: General: Alert and oriented x 4, no apparent distress, normal level of consciousness, good personal hygiene. HEENT: Positive for erythema of throat, exudate of throat. No gross deformity, sclerae anicteric, normal conjuctivae, PERRLA, no sinus tenderness, no boggy nasal mucosa, no lesions of the throat, no enlargement of tonsils, tympanic membrane clear. ABDOMEN: Soft, non-tender, no surgical scars, no trauma on inspection, normal bowel sounds x 4, no masses noted on light or deep palpation, no hepatosplenomegaly, no rebound tenderness. LUNGS: Lungs are clear to auscultation and percussion bilaterally, no adventitious breath sounds. Diagnostic results: Rapid strep test- negative throat culture- negative This study source was downloaded by 100000805030033 from CourseHero.com on [Show More]

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