Annotated-NR 20509 20week 202-1 SOAP NOTE
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Annotated-NR 20509 20week 202-1 SOAP NOTEOnset Intermittent chest tightness the last couple of days after being near cats Location Chest tightness all over Duration Intermittently the past two days Ch ... aracteristics Chest tightness no pain. Aggravating Factors Worse at night and lying down, cats, and dust. Relieving Factors Albuterol inhaler Treatment Proventil 90mcg inhaler 3 puffs every 4 hours. Current Medications: Include dosage, frequency, length of time used and reason for use; also include OTC or homeopathic productsCC 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 symptomAsthma dx age 2.5 yrs old, Diabetes dx at 24yrs old,Denies surgical history, last hospital admission at 16 yrs old for asthma exacerbation. Reports all Immunization are current at this visit, Last Flu vaccine: declines at this time Last Tetanus booster: last year Social History (Soc Hx) - Includes but not limited to occupation and major hobbies, family status, tobacco and alcohol use, and any other pertinent data. Include health promotion such as use seat belts all the time or working smoke detectors in the house. [Show More]
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