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NURSING > CASE STUDY > NR509 SOAP Note WEEK 7 (All)

NR509 SOAP Note WEEK 7

Document Content and Description Below

NR509 SOAP Note WEEK 7 Initials: Danny Age: 8 Gender: male Height Weight BP HR RR Temp SPO2 Pain Allergies Click or tap here to enter text. Click or tap here to enter text. 120/ 76 100 28 37.2C 96% RA Medication: none Food: none Environment: none History of Present Illness (HPI) Chief Complaint (CC) c/o cough, runny nose, right ear pain,sore throat 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 Cough, runny nose-5 days ago, right ear pain and sore throat since yesterday Location Right ear, chest, throat, nose Duration Reports constant cough and runny nose for 5 days day and night, keeps him awakw at night. States sore throat/ right ear pain are constant since yesterday Characteristics Reports a clear wet, gurlgy persistent cough, worsening at night, but not with lying flat. Denies chills, fever, bodyaches or weakness,but states he is tired since onset of cough, mild sore throat without difficulty swallowing, right ear pain and a persistent clear runny nose. Denies nausea, vomiting or diarrhea, shortness of breath or trouble with deep breathing. Denies decrease in acitivties, or appetite. Aggravating Factors Nothing makes it worse- denies knowing any triggers. Relieving Factors Moms pruple cough medicine this morning Treatment Purple cough medicine this am. 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 Purple Cough Syrup 1 dose once One time cough OTC multivitamin 1 pill daily Unknown “ for health” 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. Click or tap here to enter text. Click or tap here to Click or tap here to enter Click or tap here Click or tap here to enter text. S

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