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NR509 Week 3 SOAP Note
S: Subjective
Information the patient or patient representative told you. Initials: JT Age: 28 years Gender: Female Height: 170cm Weight: 88kg BMI: 30. BP: 139/ HR: 82 RR: 16 Temp: 98. SPO2: 99% Pain (1-10): 3/ Allergies Medication: Penicillin—Rash Food: No known allergy Environment: Cats—Asthma exacerbations History of Present Illness (HPI) 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 Chief Complaint (CC): Headache and neck stiffness Onset: Ms. Jones reports experiencing headaches and neck stiffness for approximately 5 days. She reports, 1 week ago, being the restrained, front passenger in her friend’s car when they were rear-ended at low speed. Location: Head and neck Duration: Approximately 5 days Characteristics: Dull ache to the crown and back of head. Stiffness of neck Aggravating Factors: Physical activity Relieving Factors: Tylenol Treatment: NA Current Medications
Medication Dosage Frequency Length of Time Used Reason for Use Proventil inhaler Albuterol 90mcg/spray PRN Long term Asthma Tylenol 500mg PRN Unknown Headaches Advil 600mg TID PRN Unknown Menstrual cramps 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. She has asthma and diabetes type II and exhibits signs and symptoms of peripheral neuropathy to the bilateral soles of the feet. She denies any surgical history and reports that her last hospitalization for asthma when she was in high school. She also reports intermittent headaches and blurry vision whenever she has been studying for long periods of time. She denies having been to an optometrist since she was a child. She reports being treated by a respiratory specialist until the provider moved away in the past few years. She reports that she is up to date on all childhood immunizations. Until seeking primary care at this clinic 11 months ago, she was non-compliant with all health management regimen for several years. 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 Ms. Jones is very active in church and with family, goes out occasionally with friends dancing, and enjoys bible study and volunteering with her church. She previously lived alone but moved back in with her mom and younger sister to help with finances after the death of her father. She is working on her bachelor’s degree in accounting. She does not use tobacco products or illicit drugs but reports that she tried both when younger. Ms. Jones drinks diet coke soda and drinks alcohol socially a couple times per month. She is currently single, not sexually active and not taking contraceptives but used birth control while sexually active with previous partner. She has never been married and has never been pregnant. She reports a total of three (guy) partners and denies any history of STI’s. 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. Ms. Jones denies family history of migraines, seizures, Alzheimer’s, and epilepsy but reports family history of CVA. Ms. Jones’ mom is fifty years old and has hyperlipidemia and hypertension. Her dad is deceased at fifty-eight years in age from a motor vehicle accident that occurred last year but had a history of hypertension, hyperlipidemia, and type II diabetes. Her paternal grandmother has hypertension. Her paternal grandfather (Grandpa Jones) died in his early sixties from colon cancer and had a history of type II diabetes. Ms. Jones’ maternal grandmother (Nana) died at age seventy-three from a stroke and had a history of hypertension and hyperlipidemia. Her maternal grandfather (Poppa) died at age seventy-eight from a heart attack and had a history of hypertension and hyperlipidemia. Ms. Jones has a younger sister and also has asthma. Her brother has no known medical problems, but Ms. Jones reports that he is overweight as well as most of her family. Her paternal uncle is an alcoholic. Review of Systems (ROS): Address all body systems that may help rule in or out a differential diagnosis Constitutional If patient denies all symptoms for this system , check here: Denies all symptoms for this system Check the box next to each reported symptom and provide additional details.
Respiratory If patient denies all symptoms for this system , check here: Denies all symptoms for this system Check the box next to each reported symptom and provide additional details. Check if Positive Symptom Details Cough Hemoptysis Dyspnea Pain on Inspiration Other: Neuro patient denies all symptoms for this system , check here: Check the box next to each reported symptom and provide additional details. Check if Positive Symptom Details Syncope or Lightheadedness X Headache Persistent for past week, since car accident Numbness Tingling Sensation Changes RUE LUE RLE LLE Speech Deficits Other Cardiac and Peripheral Vascular If patient denies all symptoms for this system , check here: Denies all symptoms for this system Check the box next to each reported symptom and provide additional details. Check if Positive Symptom Details Chest pain SOB Exercise Intolerance Orthopnea Edema Murmurs Palpitations
Faintness Occlusions Claudications PND Other MSK If patient denies all symptoms for this system , check here: Check the box next to each reported symptom and provide additional details. Check if Positive Symptom Details x Pain Head x Stiffness Neck Crepitus Limited ROM (^) RUE LUE RLE LLE Redness Misalignment Other GI If patient denies all symptoms for this system , check here: Denies all symptoms for this system Check the box next to each reported symptom and provide additional details. Check if Positive Symptom Details Nausea/Vomiting Dysphasia Diarrhea Appetite Change Heartburn Blood in Stool Abdominal Pain Excessive Flatus Food Intolerance Rectal Bleeding Other GU If patient denies all symptoms for this system , check here: Denies all symptoms for this system
O: Objective
Information gathered during the physical examination by inspection, palpation, auscultation,
and percussion. If unable to assess a body system, write “Unable to assess”. Document
pertinent positive and negative assessment findings.
Hematology/Lymphatics If patient denies all symptoms for this system , check here: Denies all symptoms for this system Check the box next to each reported symptom and provide additional details. Check if Positive Symptom Details Anemia Easy bruising/bleeding Past Transfusions Enlarged/tender lymph node(s) Blood or lymph disorder Other: Endocrine If patient denies all symptoms for this system , check here: Denies all symptoms for this system Check the box next to each reported symptom and provide additional details. Check if Positive Symptom Details Abnormal growth Increased appetite Increased thirst Thyroid disorder Heat/cold intolerance Excessive sweating Diabetes Other: Body System Positive Findings Negative Findings General (^) Alert and oriented to person/place/time/situation, well nourished, well groomed, dressed appropriately, has adequate hygiene, and interacts appropriately. Skin Pink, warm, dry, intact, appropriate to ethnicity with acne symptoms to generalized face.
HEENT Oriented to person, place and time Abstract thinking intact, attention span normal, able to follow directions, remote and immediate memory intact, new learning ability accurate, vocabulary normal complexity, no problems with articulation Sense of smell intact bilaterally Visual Acuity: OD 20/20, OS 20/40 Pupils: PERRL Extraocular eye movements normal bilaterally, convergence normal Head and face symmetrical Weber and Rinne test normal Gag reflex intact Tongue symmetrical, no abnormal findings Respiratory Neuro (^) Headaches, alert and oriented to person/place/time/situation Facial sensation intact Sensation in arms and legs normal bilaterally Graphesthesia normal Stereognosis test normal bilaterally Decreased sensation indicative of diabetic neuropathy noted to bilateral feet Cardiovascular Musculoskeletal Active ROM in all extremities Shoulder shrug symmetrical strength 5+ Neck strength 5+ All DTR’s 2+, normal Finger to nose and heel to shin normal/smooth and accurate Gait steady and symmetric Gastrointestinal Genitourinary Psychiatric Gynecological Hematology/Lymphatic Endocrine Problem List Order Item 1 Persistent headaches x1 week 2 Neck Pain/Stiffness
110mg/spray Tylenol Recommended dose Continue previous meds Tension headache regimen Advil Recommended dose Continue previous meds Pain regimen
Referral/Consults:
None at this time: Referral/Consults: Rationale/Citation No referral needed at this time
Education:
None at this time: Education Rationale/Citation Education related to RICE Therapy, Education regarding non-pharmacologic pain management techniques Follow-Up: Indicate when patient should return to clinic and provide detailed instructions indicating if the patient should return sooner than scheduled or seek attention elsewhere. None at this time: Follow-Up Rationale/Citation Follow up PRN for unresolved pain concerns or worsening symptoms References ( Include at least one evidence-based peer-reviewed journal article which relates to this case. Use the correct APA 6th edition formatting.) List references below: Ascriva health Informatics. (2019). ICD-10-CM-2019 App, Version 2.4.
