Physical Education > EXAM > NR 509 Week 3 Neurology SOAP Note (version 1) 2022 update, complete template solutions. (All)

NR 509 Week 3 Neurology SOAP Note (version 1) 2022 update, complete template solutions.

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SOAP Note Template Initials: T.J. Age: 28 years old Gender: F Height Weight BP HR RR Temp SPO2 Pain Allergies 170 cm 88 kg 139/ 87 82 16 98.9 99% Choose an item. Medication: Penicillin (cause ... s rash/hives) Food: NKA Environment: Cats; dust (causes asthma exacerbation) History of Present Illness (HPI) Chief Complaint (CC) Headaches and sore neck 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 Low speed car accident 1 week ago; symptoms began 2 days after accident Location Headache: crown and back of head; pain 3/10 Neck: back of neck into head; pain 3/10 Duration Five days – every day lasting 1-2 hours Characteristics Headache: dull Neck: stiff Aggravating Factors Neck movement Relieving Factors Medication (Tylenol) and rest Treatment Medication (Tylenol) 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 Tylenol “regular strength” per pt Daily 5 days Headache Flovent Pt unsure Daily 8 months Asth [Show More]

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