SOAP NOTE Scenario # 3 Patient Initials: __MH_____ Age: _20____ Gender: _F_ SUBJECTIVE DATA: Chief Complaint (CC): Vomiting X 3 and nausea over 48 hours + fever today History of Present Il... lness (HPI): MH is a 20-year-old female that presents to the clinic with vomiting X 3 and nausea over the past 48 hours and fever that started this morning. She reports that she ate at a new restaurant three days ago with two of her friends and had shellfish. She reports that her friends are both having similar symptoms. She says she been nauseous since her symptoms started with no relief. She took Tylenol 325mg X 2 tablets for her fever this morning which seems to be working so far. Medications: 1. Tylenol 325mg X 2 – PO as needed for pain, fever 2. Ibuprofen 200mg – 2 PO as needed 3. Seasonique – 1 PO daily for birth control Allergies: None Past Medical History (PMH): Appendicitis Past Surgical History (PSH: Appendectomy – 2008, wisdom teeth extraction - 2011 Sexual/Reproductive History: Heterosexual Personal/Social History: She is a non-smoker; denied ETOH or illicit drug use. Immunization History: Her immunizations are up to date. Significant Family History: One sister that is 25, health, away at college. Both parents are alive. Her mother is healthy, and her father has hypertension. She thinks he was diagnosed a couple years ago and takes medication for it. Lifestyle: She lives at home with her parents, works part-time at a store in the mall, and takes classes at local community college. She has her own care; however, her parents help with insurance. She is still on her parent’s health insurance plan and sees her doctor for annual and routine care and as needed for episodic care. She has a healthy diet, and exercises 4 to 5 days a week. She has a good support system composed of family and friends. Reference Ball, J. W., Dains, J. E., Flynn, J. A., Solomon, B. S., & Stewart, R. W. (2015). Seidel's guide to physical examination (8th ed.). St. Louis, MO: Elsevier Mosby. BetterMed urgent care. (2014). Is your stomach ache a bug or food poisoning? Retrieved from http://bettermedcare.com/is-your-stomach-ache-a-bug-or-food-poisoning.html Center for Disease Control and Prevention. (2016). Flu symptoms & complications. Retrieved from http://www.cdc.gov/flu/about/disease/complications.htm Food Allergy Research & Education. (2016). Symptoms. Retrieved from https://www.foodallergy.org/symptoms [Show More]
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