Nursing > SOAP NOTE > Tina jones (T.J) . SOAP Note week 3 Neuro. Contains Subjective informations; History of Present Illn (All)

Tina jones (T.J) . SOAP Note week 3 Neuro. Contains Subjective informations; History of Present Illness (HPI); Current Medications; Past Medical History (PMHx); Family History (Fam Hx); Review of Systems (ROS).

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SOAP Note Template Initials: T.J. Age: 28 Gender: Female Height Weight BP HR RR Temp SPO2 Pain Allergies 170 cm 88 kg 139/ 87 82 16 98.9 F 99% 3/10 Medication: Penicillin-Rash/Hives Food: No k... nown food allergies Environment: Cats & Dust-Sneezing, itchy eyes, asthma flare ups. History of Present Illness (HPI) Chief Complaint (CC) “Well I got into a fender bender a week ago and I’ve been getting these headaches ever since and my neck is sore too” 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 5 days ago ( days post accident) Location Head and neck Duration Headache occurs once a day, last 1-2 hours Characteristics Dull ache in the crown and back of the head bilaterally, pain in the bilateral temples and behind the eyes. Aggravating Factors Denies any aggravating factors for headache, but states neck soreness is exacerbated and painful with movement of the head/neck. Relieving Factors Tylenol and rest Treatment Currently takes Tylenol 2 regular strength one a day for headache and neck pain since accident. 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 Tylenol (Acetaminophen) Regular Strength Two 325mg tablets Once a day 7 days Daily headaches, and neck pain Proventil Inhaler (Albuterol) 90 mcg (1-2) puffs PRN as needed. (last used 8 months ago) Since diagnosis of asthma at age 2.5 Asthma Exacerbation Advil (Ibuprofen) Three 200mg tablets PRN up to three times a day Unknown, takes during menstrual cycle Takes during menstrual cycle for cramps Flovent 44 mcg (2 puffs) Daily BID New Asthma References Include at least one evidence-based peer-reviewed journal article which relates to this case. Use the correct APA 6th edition formatting. American College of Radiology. (2019). ACR appropriateness criteria. Retrieved from https://acsearch.acr.org/docs/69482/Narrative/ Centers for Disease Control and Prevention (CDC). (2019). ICD-10-DM tabular list of diseases and injuries. Retrieved from:https://ftp.cdc.gov/pub/health_statistics/nchs/publications/ICD10CM/2019/icd10cm_tabular_2019.pdf John Hopkins Medicine. (2019). Headache. Retrieved from: https://www.hopkinsmedicine.org/health/conditions-and-diseases/headache Mishra, S. C., Chhatbar, K. C., Kashikar, A., & Mehndiratta, A. (2017). Diabetic foot. BMJ (Clinical research ed.), 359, j5064. doi:10.1136/bmj.j5064 Solomon, S. D., Chew, E., Duh, E. J., Sobrin, L., Sun, J. K., VanderBeek, B. L. Wykoff, C. C., & Gardner, T. W. (2017). Diabetic retinopathy: A position statement by the American Diabetes Association. Diabetes Care, 40(3), 412-418. https://doi.org/10.2337/dc16-2641 Tanaka, N., Atesok, K., Nakanishi, K., Kamei, N., Nakamae, T., Kotaka, S., & Adachi, N. (2018). Pathology and Treatment of Traumatic Cervical Spine Syndrome: Whiplash Injury. Advances in orthopedics, 2018, 4765050. doi:10.1155/2018/4765050 [Show More]

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