NR509- week 3 SOAP_Note final.
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Should include: the accident MVA, should pertain to the Chief complaint, 15mile accident in parking lot, wearing seat belt, rear end fender bender. Was not drinking alcohol. (Asthma dx age 2.5 yrs ol... d, Diabetes dx at 24yrs old, Denies surgical history, last hospital admission at 16 yrs old for asthma exacerbation. Reports all Immunization are current at this visit, Last Flu vaccine: 5 or 6 years ago per patient, declines at this time Last Tetanus booster: two years ago Reports Meningitis Vaccine at 19yrs old. 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. Supervisor at Mid-American Copy & Ship, Bachelor’s accounting student, Hobbies:Reading, watchingTV, hanging with friends and going to church. Close with mother and sister (living together), Brother lives with fiancee, father deceased from car accident. Denies tobacco use. Alcohol use socially with friends ( rum and diet coke drink of choice). Drives and always uses a seatbelt, working smoke detector in house. 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. Mother- high cholesterol and hypertension Father (deceased at 58 car accident 2 years ago)- Hx of Diabetes, high cholesterol and hypertension Brother 25 y.o.- Obesity Sister 14 yrs old- dx age 2 or 3 with asthma. maternal grandma- HTN and high cholesterol maternal grandpa-HTN and high cholesterol. paternal grandma-HTN and high cholesterol paternal grandpa- (deceased) colon cancer, HTN, diabetes. [Show More]
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