Chamberlain College of Nursing - NR 509 Soap.Note.Respiratory.TinaJones. (complete updated 2021)

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SOAP Note Template Initials: TJ Age: 28 years old Gender: Female Height Weight BP HR RR Temp SPO2 Pain Allergies 170cm 88 kg 139/8 7 82 16 98.9 99% 3/10 Medication: Penicillin (causes rash and hi... ves) Food:None Environment: Cats, dust (cause asthma exacerbation) History of Present Illness (HPI) Chief Complaint (CC) Headaches with neck pain 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 1 week ago after car accident, symptoms because 2 days after accident. Location Headache at the crown and back of the head Duration Lasts 1-2 hours daily Characteristics Dull pain while experiencing headache Aggravating Factors Pain when moving her neck Relieving Factors Rest and Tylenol as needed Treatment (PRN) As needed two regular strength 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 90 mcg 2 puffs as needed Every 4 hours as Wheezing S: Subjective Information the patient or patient representative told you needed Shortness of breath Tylenol 650 mg (states she takes two tablets) Once a day The past few days Headaches Advil 200 mg TID PRN First couple of 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, hospitalizations, and surgeries. Depending on the CC, more info may be needed. Tina was diagnosed with Diabetes Mellitus type 2 at the age of 24 years old. She is non-compliant with taking her metformin, as well as checking blood sugar on a regular basis. Diagnosed with asthma at the age of 2 and a half. Has been taking her inhaler as needed for asthma exacerbation; currently it is not being as effective as it was. Is now on Flovent which has been providing relief for maintenance. Suffers from heavy periods that include cramping as well as tenderness. Tina has irregular periods which last between 9-10 days. Immunizations are current, has received vaccinations for childhood. Flu shot received last 5 to 6 years ago. Last tetanus shot was about two years ago. Last pap smear was done about 4 years ago, and was normal. Tina has Polycystic ovarian syndrome. 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. Patient denies smoking, denies recreational drug use. Patient is a former pot smoker who quit when she was 20 or 21 years old. She is occasionally exposed to second hand smoke socially as her friends smoke. Drinks alcohol occasionally, about 6 drinks a month. Patient is currently a student working on obtaining her bachelors degree in accounting. Patient lives with her mother and sister who support her dreams. Patient became sexually active at the age of 18 and has had 3 male sexual partners in total. Denies using birth control at the moment. 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 perti- nent. Mother history of HTN and high cholesterol. Father history of HTN, diabetes mellitus type 2, high cholesterol ( Passed away in car accident). Paternal grandmother history of HTN and high cholesterol. Paternal grandfather history of HTN, diabetes, colon cancer (passed away from colon cancer). Brother is obese. Sister has asthma. Maternal grandmother history of hypertension, and high cholesterol (deceased from stroke at 73 years old) Maternal grandfather HTN, high cholesterol. 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: ☐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. ☐XVision 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 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. 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 Choose an item. Choose an item. Choose an item. ☐Other: Click or tap here to enter text. ☐Syncope or Lightheadedness Click or tap here to enter text. ☐XHeadache Started recently 2 days after low speed car accident, headache occurs daily for 1-2 hours at a time. Pain is described as dull, and located at the crown and back of the head. ☐Numbness Click or tap here to enter text. ☐Tingling Click or tap here to enter text. ☐Sensation Changes Choose an item. ☐Speech Deficits Click or tap here to enter text. ☐Other: Click or tap here to enter text. ☐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. MSK GI GU PSYCH ☐XPain Neck pain with movement of head and neck ☐XStiffness stiffness to neck ☐Crepitus Click or tap here to enter text. ☐Swelling Click or tap here to enter text. ☐xLimited 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. ☐XLMP: N/A ☐Contraception Click or tap here to enter text. ☐Other:Click or tap here to enter text. Body System Positive Findings Negative Findings General Unable to assess Click or tap here to enter text. Click or tap here to enter text. Skin Unable to assess Click or tap here to enter text. Click or tap here to enter text. HEENT Unable to assess Click or tap here to enter text. Click or tap here to enter text. Respiratory Unable to assess Click or tap here to enter text. Click or tap here to enter text. Neuro Cranial nerve 2 (optic) Right Fundus has cotton wool bodies present. Decreased sensation to bilateral feet. Tina is oriented to person, place and time Her abstract thinking responses were intact and relevant She is able to follow simple commands Attention span was accurate, intact as well as general knowledge was accurate Remote memory and immediate memory are intact Vocabulary is complex as expected for her age, education level and general ability. No apparent problems with pronunciation or expression. Cranials Nerves: Olfatory I: sense of smell is intact, nose symmetrical bilater [Show More]

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