Jones Tasha Soap Note | Complete soap Note
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Course # NSG 6665 Complete SOAP Note Subjective Data: ● Chief complaint (CC): “I am here for a physical examination.” ● HPI: 49 year old African-American female presented to the clinic req... uesting a physical examination. ● PMH: Adult Illnesses: HTN, High Cholesterol. Hospitalization 1987 (Natural Childbirth) Childhood Illnesses: Mumps, Chickenpox ● PSH: Natural Childbirth (1980) C-Section (1992) Bunionectomy (1999) ● Current Health Status: 1. Allergies: Denies 2. Tobacco use: Denies 3. Alcohol use: glass of Red wine socially twice month 4. Illicit Drug: Denies 5. Current medications: a. Zocor 20mg PO at bedtime for high cholesterol b. Hydrochlorothiazide 12.5 PO daily for HTN c. Advil 200mg 2 tabs PO BID prn pain 6. Injuries: Denies 7. Environmental hazards: Patient denies exposure to environmental hazards at home or work. She states she lives in a single dwelling home with her adult sister and brother. No loose rugs or obstructing furniture. No stairs to enter home or within home. No small pets 8. Screening tests: Eye exam 2016, 20/20 bilaterally with contacts, dental exam 11/2016, hearing exam normal results 2016. last Mammogram 2014. 9. Safety measures: confirms use of seat belts while riding in vehicles; wears helmet when riding bike. 10. Immunizations: Flu shot- 8/3/2016. Does not take pneumonia vaccine. States immunizations up to date. HBV, MMR, Varicello 10/2016. 11. Exercise and leisure: [Show More]
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