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*NURSING > CASE STUDY > NR509 week 5 SOAP Note (All)

NR509 week 5 SOAP Note

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SOAP Note Template Initials: E.P. Age: 78 Gender: Female Height Weight BP HR RR Temp SPO2 Pain Allergies 5’ 2 120lbs 110/ 70 92 16 37.0C 99% Medication: NKDA Food: Denies Environment: Latex ( ... itchy skin rash) dx at age 54 History of Present Illness (HPI) Chief Complaint (CC) “Belly pain” 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 Location Lower abdomen Duration Constant. Worse when moving or when eating. ( worse 2-3 days) Characteristics Constant. Dull and crampy. Generalized pain that stays in one place. (Last BM 5 days ago, non- radiating worsedn over 2-3 days) (Add associated char diarrhea, last BM) Aggravating Factors Moving or after eating (put how it helped: little help ) Relieving Factors Resting and not moving ( put the degree of improvement what the pain is at after intervention) Treatment None (sips of water no help, Anything they did even if tx did not work) 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 Accupril (research med side effect coud be a DDX) 10mg Daily 24 yrs Hypertension N/A 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. N/A 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. N/A 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. N/A Click or tap here to enter text. Click or tap here to enter text. Click or tap he [Show More]

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