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*NURSING > QUESTIONS and ANSWERS > NURS_6531_SOAP_NOTE_NUMBER (All)

NURS_6531_SOAP_NOTE_NUMBER

Document Content and Description Below

Week 3 Episodic SOAP Note #1 Patient Information: A.A., 20, Female, Caucasian S. CC: Sore throat, flu-like symptoms HPI: 20-year-old college student presents to office complaining of sore throat ... , pain with swallowing, decreased appetite, headaches, runny nose and a slight hoarseness in her throat. Patient states her symptoms began approximately 3 days ago and denies any congestion in her voice. Patient admits that she is aware of flu-like symptoms have been “going around” at her campus. Current Medications: self-medicated with Tylenol for headaches as needed. Allergies: negative for any allergies to food and drugs PMHx: Updated immunization status for TDAP, Flu vaccine Soc Hx: Negative for tobacco abuse, alcohol consumption and use of illicit drugs. Patient is in college and a a heterosexual single female who dates casually and practices safe sex using birth control and condoms. Fam Hx: Mother is age 55 with no PMH and Father is age 57 who is a prostate cancer survivor. Patient denies diabetes, cardiovascular disease and stroke in her first-degree relatives. ROS: GENERAL: Positive for fatigue; negative for weakness, fever, no significant weight change. HEENT: Positive for headache, runny nose, hoarseness; negative for head injury, dizziness, lightheadedness, vision changes, hearing problems, tinnitus, vertigo, earaches, nosebleeds, sinus trouble, and dry mouth. SKIN: No rash or itching. CARDIOVASCULAR: No chest pain, chest pressure or [Show More]

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