Chamberlain College of Nursing – NR602 wk2 Soap: SOLVED and Graded A

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Soap L.F,15 and 1/2 years, F S: CC: “Sports physical, not started menses yet, Birth control pill . HPI: Kayla brings Lily in for a sport physical, needed prior to the initiation of school, becau... se Lily would like to play volleyball. Mother is present throughout your initial history gathering. Lily will be a sophomore. She expresses angst at starting a new school and leaving her friends for the recent move. She sleeps 6 to 7 hours per night. She denies current sexual activity upon questioning or use of drugs and alcohol. She is currently dating a local boy she met for the last month. Her mother reports she would also like to begin Lily on ‘the pill’, because “I don’t want her getting pregnant young like I did”. Her mother remains present throughout the gathering of the history. Onset: Not specified. Location: whole body, generalized Duration: unknown. Characteristics: none Aggravating Factors: none Relieving factors: n/a Treatment: n/a. PMH: full-term vaginal delivery weighed 8 lbs. She experienced a right radial fracture at age 5 and tonsillectomy and adenoidectomy at age 7. Current medications: None Surgeries: None Allergies: None Vaccination History: Mother states, “She had all of her shots up to kindergarten, but I don’t think she has needed any since then Social history: Lily will be a sophomore. She expresses angst at starting a new school and leaving her friends for the recent move. She sleeps 6 to 7 hours per night. She denies current sexual activity upon questioning or use of drugs and alcohol Family History: None ROS Constitutional: Have you lost or gained weight over time? Do you have change in your appetite? Do you or have you had weakness or fatigue? Do you or have you had any fever or chills? HEENT: Eyes: Do you have any visual loss, blurred, vision, pain, redness, or discharge from the eyes? Do you wear corrective lenses? Have you had any trauma to the eyes? Ears/Nose/Throat: Do you have a hearing loss or changes in hearing? Do you feel any changes in the sense of smell? Do you have sore throat, difficulty swallowing, any postnasal drip, or changes in taste? Neuro: Do you have headaches, loss of consciousness, dizziness, syncope, or numbness/tingling in the extremities? Do you have history of sustaining head trauma or concussion? Any history of loss of consciousness or seizures? Any history of headaches? Have you” or pinched nerve? Do you have any numbness, tingling, or paralysis of limbs? Do you ever drink or use drugs when you're alone? Cardiovascular: Have you ever passed out, felt dizzy, had chest pain, palpitations, heart murmurs, heat illness, or trouble breathing during exercise? Any recent viral illness that may indicate cardiomyopathy? Are you experiencing excessive fatigue with activities Have you ever had a history of heart problems? Is there a family history of premature or sudden death? Any history of hypertension or any specific cardiac problems in the family? Respiratory: Have you or do you have any shortness of breath or coughing? Do you have shortness of breath while completing daily tasks and activities? Do you have a history of asthma, wheezing, dyspnea with activities or other pulmonary problems Gastrointestinal: Have you had or do you have abdominal pain? Have you had any nausea, vomiting or diarrhea? Genitourinary: Reports no menses yet. Do you have any abnormal vaginal bleeding? Have you had any irregular bloody virginal discharge? Have you ever used any kind of contraceptive devices or methods? Do you have any difficulty urinating or burning? Have you been diagnosed with UTI? Are you sexually active, if yes, do you have multiple sex partners? Do you use condoms every time you have intercourse? Musculoskeletal: Do you have muscle weakness, back pain, joint pain, or stiffness? Any history of sprains strains, fractures, tendonitis, dislocations, or subluxations? Skin: Any skin infections or lesions? Do you have piercings/tattoos? Hematologic: Do you have fatigue, dizziness, or abnormal bruising or bleeding? Lymphatics: Do you have any enlarged lymph nodes? Psychiatric: Lily “expresses” angst at starting a new school and leaving her Do you feel anxious or depressed? Do you have any sleeping problems at night? Have you had any significant changes in your life recently? Have there been any changes in your eating habits? Do you hear any voices or see any unusual things? Are you taking any prescribed or OTC medications/supplements? Have you ever taken diet pills? Do you have any body image concerns? Have you ever been picked on or bullied? Reference Casey, P., & Bailey, S. (2011). Adjustment disorders: the state of the art. World Psychiatry, 10(1), 11–18. doi:10.1002/j.2051-5545.2011.tb00003.x Greenwood, D. C. (2012). Meta-analysis of observational studies. Modern Methods for Epidemiology, 173–189. doi:10.1007/978-94-007-3024-3_10 Seidel, H. M., Ball, J. W., Dains, J. E., Flynn, J. A., Solomon, B. S., & Stewart, R. W. (2011). Sports participation evaluation. Mosby’s Guide to Physical Examination, 749–759. doi:10.1016/b978-0-323-05570-3.00023-0 Sharma, S., Merghani, A., & Gati, S. (2015). Cardiac screening of young athletes prior to participation in sports. JAMA Internal Medicine, 175(1), 125. doi:10.1001/jamainternmed.2014.6023 Lobo, R. A. (2013). Primary and secondary amenorrhea and precocious puberty. Comprehensive Gynecology, 815–836. doi:10.1016/b978-0-323-06986-1.00038-x Marsden, J. (2014). Mosby’s manual of diagnostic and laboratory tests: Pagana Kathleen and Pagana Timothy mosby’s manual of diagnostic and laboratory tests. Elsevier. Emergency Nurse, 22(4), 13–13. doi:10.7748/en.22.4.13.s14 Stettler, N., Bhatia, J., Parish, A., & Stallings, V. A. (2011). Feeding healthy infants, children, and adolescents. Nelson Textbook of Pediatrics, 160–170.e1. doi:10.1016/b978- 1-4377-0755-7.00042-7 [Show More]

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