NR509 Week 6 SOAP Note

Document Content and Description Below

SOAP NOTES TEMPLATE S: Subjective Information the patient or patient representative told you. Initials: DR: Age: 8 years old Gender: Male Height: 4’2” Weight: 90lbs BP: 120/91 HR: ... 100 RR: 28 FVC: 3.91 FEV1: 3.15 FEV1/FVC: 80.5% Temp: 37.2C SPO2: 96% Pain (1-10): 3 Allergies Medication: NKDA Food: No known food allergies Environment: No known environmental allergies History of Present Illness (HPI) Chief Complaint (CC): Cough Onset: 5 days ago Location: Chest Duration: Frequent (every couple of minutes without trigger noted) Characteristics: Wet, productive with clear sputum Aggravating Factors: Unknown triggers Relieving Factors: Cough medicine alleviated the cough for a short amount of time Treatment: Cough syrup today Current Medications Medication Dosage Frequency Length of Time Reason for Use SOAP NOTES TEMPLATE Used Kids Multivitamin Gummies Recommended dosing Daily Unknown Health maintenance Cough Syrup Recommended dosing PRN Unknown Cough treatment Past Medical History (PMHx)— Danny is an 8-year-old male that denies any history of allergies to medications, foods, seasonal, latex or environmental agents. He reports having frequent colds and being diagnosed with pneumonia last year. He takes a daily dose of children’s multivitamin gummies as well as PRN doses of cough syrup to treat episodes of coughing. He reports that his immunizations are up to date and denies any other history of major illnesses (including asthma), hospitalizations, or surgeries. Social History (Soc Hx)— Danny is a 3rd grade student with a reported history of missing school for two weeks last year due to pneumonia. He lives with his mother and father and is cared for by his grandmother while his parents are working. English is the primary language spoken in the home with Spanish as an alternate language utilized. Family History (Fam Hx)— Danny’s mother has type II diabetes, hypertension, hypercholesterolemia, spinal stenosis, and is obese Danny’s father is a smoker (cigars), and has hypertension, hypercholesterolemia, as well as a childhood history of asthma Danny’s grandparent’s history: Maternal— Grandmother: type II diabetes and hypertension Grandfather: Smoker and eczema Paternal— Grandmother: died in a car accident at 52 years of age Grandfather: No known history 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: Check the box next to each reported symptom and provide additional details. Check if Symptom Details SOAP NOTES TEMPLATE Positive x Fatigue “kind of tired” Weakness Denies Fever/Chills Denies Weight Changes Denies Trouble Sleeping Denies Night Sweats Denies Other Denies Skin If patient denies all symptoms for this system, check here: Denies all symptoms Check the box next to each reported symptom and provide additional details. Check if Positive Symptom Details Itching Rashes Nail Skin Color Other HEENT 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 Diplopia Denies Eye Pain Denies Eye redness Denies Vision changes Denies Photophobia Denies Eye discharge Denies Eye discharge Denies x Earache x2days, right ear Tinnitus Denies Vertigo Denies Hearing Changes Denies Hoarseness Denies x Sore Throat Reports “a little” pain and soreness x Congestion “my cough seems kind of wet and gurgly” x Rhinorrhea “my nose always runs a little, but it is worse since the cough started” SOAP NOTES TEMPLATE Other Denies Respiratory 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 Cough Frequent coughing without much relief from cough syrup Hemoptysis Denies Dyspnea Denies Dyspnea Denies Pain on Inspiration Denies Other Denies Neuro patient denies all symptoms for this system, check here: Denies all symptoms Check the box next to each reported symptom and provide additional details. Check if Positive Symptom Details Syncope or Lightheadedness Headache 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 Check the box next to each reported symptom and provide additional details. Check if Positive Symptom Details Chest pain SOB Exercise Intolerance SOAP NOTES TEMPLATE Orthopnea Edema Murmurs Palpitations Faintness Occlusions Claudications PND Other MSK If patient denies all symptoms for this system, check here: Denies all symptoms Check the box next to each reported symptom and provide additional details. Check if Positive Symptom Details Pain Stiffness Crepitus Limited ROM RUE LUE RLE LLE Redness Misalignment Other GI If patient denies all symptoms for this syste [Show More]

Last updated: 3 years ago

Preview 1 out of 13 pages