NURSING NSG 6020 / NSG6020 SOAP NOTE WEEK 6

NURSING NSG 6020 / NSG6020  SOAP NOTE WEEK 6  PATIENT ENCOUNTER SOAP NOTE Name:   Y. B. Date:  10/29/18 Time:  1430 Age:  38 Sex:  Female SUBJECTIVE   CC: “I have had the worst headache ...

NURSING NSG 6020 / NSG6020  SOAP NOTE WEEK 6  PATIENT ENCOUNTER SOAP NOTE Name:   Y. B. Date:  10/29/18 Time:  1430 Age:  38 Sex:  Female SUBJECTIVE   CC: “I have had the worst headache of my life for the past 3 days” HPI:   Y. B. is a 38-year-old white female that presents to the office on 10/31/18 with 3 days of headache. The headache started in the morning 3 days ago and lasts all day. She states that the headache is on one side of her head, behind her eyes and sinus region. She rates the pain a 10/10 and describes it as a pulsating/throbbing pain. Y.B. states that sleep is the only thing that gives her some relief from this headache while; noise and light makes the headache worse. She denies ever having a headache like this before in her life. Medications: Denies any herbal or fold medicine None - patient states that she is not currently on any medication. PMH “I think I’m pretty healthy, I just need to lose some weight”. Patient reports she has had 2 C-sections and hysterectomy. The hysterectomy was following her last C-section due to complications from endometriosis, which she was diagnosed with at age 26. Allergies:   NKA Medication Intolerances:   Denies Chronic Illnesses/Major traumas   Denies Hospitalizations/Surgeries   2 C-sections (childbirth) and hysterectomy Other: Immunizations: “I have had all my shots and I plan on getting the flu shot this year”. Family History Both parents are living. Mother has hypertension that was diagnosed at the age of 40 and she is currently on antihypertensive medication. Father is a smoker and has had asthma since childhood. Her grandparents on both sides are deceased. Her grandmother on her mother’s side died of complications from a stroke at age 75; She also was a smoker and a type 2 diabetic. Her grandfather on her mother’s side was a smoker with a history of sleep apnea and COPD. Her grandparents on her father’s side were healthy and died of natural causes. Y.B. is second child amongst five siblings, she has two sisters and two brothers, one of the sisters (the eldest) was diagnosed with migraine headaches at the age of 25, but otherwise healthy. She has two young boys (ages 5 and 7) who are in great health without any congenital or childhood illnesses. Social History Y. B. was born in Newton Grove, NC. She has been working as a registered nurse for the past 5 years and is currently in school for her masters. She married at age 28 and has 1 stepdaughter (age 20) and 2 sons (age 5 and 7). Y. B. lives with her husband and 2 boys in a single-family home. She states that she recently lost 50 lbs. within the past year but has gained back 20 of those pounds due to stress from balancing home life, work and school. The patient denies any smoking or illicit drug use, but she reports having an 8 oz. glass of wine twice a week, and every other weekend. Y.B. denies feeling like she needs to cut down on her drinking, denies any annoyance by criticism, denies any guilty feelings about her drinking and she denies feeling like she needs a morning eye opener. Y.B. says she enjoys spending time with her family and walking in her neighborhood two to three times a week. Denies ETOH, tobacco, marijuana. ROS General   Denies weakness, has moderate fatigue, denies fever or night sweats, rates her pain 10/10. Cardiovascular Denies chest pain, no palpitations, no orthopnea, no edema. Skin No rashes on torso, reports round and red to pink area of hair loss, reports mild to moderate itching to the area, no abnormalities of the nails Respiratory No cough, wheezing, hemoptysis, dyspnea, pneumonia.