Nursing 6531 - Week 3 Assignment

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Episodic SOAP Note NURS 6531 – Primary Care of Adults December 7, 2018 Patient Information: Initials: N. P. Age: 35 Sex: Female Race: Caucasian S. CC: “Headache, fever, and body a... ches” HPI: 35-year-old Caucasian female presents to the clinic today with complaints of a severe “migraine like” headache, fever, and generalized body aches accompanied with a mild nonproductive cough and rhinorrhea. The symptoms were first noted 3 days ago that occurred approximately 24 hours after returning home from work at the local hospital. Light tends to make her headache worse, but she does report some relief of the headache and body aches along with the fever by taking 600mg Ibuprofen. Without the use of the ibuprofen, she rates her headache 9/10 with her body aches a 4/10. Current Medications: Ibuprofen 600mg every 4-6 hours as needed for fever/moderate pain Wellbutrin 100mg BID for depression Buspar 7.5mg BID for anxiety Allergies: No known allergies PMHx: Immunizations are up to date, last tetanus received May 2016 and flu vaccine received October 2018. History of depression and anxiety, denies any previous surgeries. No prior hospitalizations except for the birth of her daughter and denies any accidents or serious injuries. Soc Hx: Ms. P was born in West Virginia and currently attends a local college for her associates degree in nursing. She lives with her significant other, therefore, she does not live on campus. She commutes to and from work at the local hospital where she has worked for the past 6 years as a certified nursing assistant. She reports the utilization of a safety belt while driving and does not use her mobile device while driving that vehicle. She is in a long-term relationship, heterosexual and is sexually active. She utilizes contraceptives since the birth of her 4-year-old daughter. She goes to the gym 2-5 times/wk when not working or doing homework. Has never smoked, intermittent alcohol use (3 blended beverages/wk) yet denies illicit drugs. Her parents and significant other are a great support system along with her 2 older siblings. Family Hx: Father age 61, acute pancreatitis s/p cholecystectomy & depression Mother age 59, DM2, HTN Siblings: 1 brother and 1 sister, all healthy with no medical history Paternal grandmother: deceased at 75 d/t myocardial infarction Paternal grandfather: 83, living, hx arthritis & prostate enlargement Maternal grandmother: deceased age 94 d/t “old age” Maternal grandfather: deceased age 71 d/t MI Review of Systems: General: No unexplained weight loss or gain, no decreased appetite, no chills, + fever & fatigue HEENT: No blurred vision or loss of vision, no loss of hearing, hearing difficulty or ringing in ears, no congestion, + for rhinorrhea, sore throat, no hoarseness. Integumentary: No changes in skin such as rashes, dryness or persistent itching Respiratory: No SOB, wheezing, rhonchi or rales, + cough, no sputum production Cardiovascular: No chest pain, + palpitations, or extremity edema, no pain with walking Gastrointestinal: No change in bowel habits, indigestions, nausea/vomiting or diarrhea. No abdominal pain or tenderness, no decrease in appetite. Genitourinary: No burning with urination, no itching. Last menstrual cycle 4/20/2018 Neurological: No dizziness, LOC, + headaches. Moves all extremities without tremors Psychiatric: No mental illness, + depression & anxiety Musculoskeletal: + muscle aches, no joint pain Hematologic: No anemia, bleeding, not easily bruised Lymphatics: + cervical lymphadenopathy, no history of splenectomy. Endocrinological: No heat or cold intolerances, no sweating, no polyuria or polydipsia. Allergies: No history of asthma, hives, eczema or rhinitis. O. Vital Signs: Ht. 5’6” Wt. 130lbs, BMI = 21, T-max 100.2, BP 121/72, pulse 116, respirations 17, o2 saturation 98% on RA. Physical Exam: General: Well-nourished but ill-looking Caucasian female HEENT: PERRLA, ears clear, + rhinorrhea, + erythema to throat, no hoarseness in voice, + for cervical lymphadenopathy. Integumentary: No rashes, dryness Respiratory: Lungs clear to auscultation bilaterally, no rhonchi, wheezing or rales, + cough, no sputum production Cardiovascular: Regular rhythm, + tachycardia without murmur or gallop, no ........................................................................Continued.............................................................. [Show More]

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