NURSING > QUESTIONS & ANSWERS > Walden University - NURSING: NURS6512 Health Assessment Week 8 discussion: SOAP NOTE Case Study #3. (All)

Walden University - NURSING: NURS6512 Health Assessment Week 8 discussion: SOAP NOTE Case Study #3. Graded A. SOAP NOTE

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SOAP NOTE Ankle Pain Patient Initials: __MH___ Age: _46____ Gender: __F____ SUBJECTIVE DATA: Chief Complaint (CC): Ankle pain bilaterally History of Present Illness (HPI): MH is a 46-year-old Caucasian female who presents today with bilateral ankle pain, with worse pain in the right ankle. The pain started after playing soccer over the weekend when she heard a “pop”. She reports that she is able to bear weight, but it is uncomfortable. She has taken Ibuprofen and Tylenol for swelling and pain that helps a little. She rated the severity of pain in her left ankle as a 2/10 and a 6/10 in the right ankle. Medications: 1.) Multivitamin daily 2.) Ibuprofen 200mg-2 PO as needed 3.) Tylenol 325mg-2 PO every 4 hours as needed Allergies: NKA Past Medical History (PMH): 1.) Asthma – when she was a child 2.) Right ankle sprain - 2015 Past Surgical History (PSH): 1.) Cholecystectomy 2000 2.) Wisdom teeth extraction 1990 Sexual/Reproductive History: Heterosexual G1P1A0 Menopausal – started 2014 Personal/Social History: She drinks occasionally; denied denies smoking or illicit drug use. Immunization History: Her immunizations are up to date. She received the influenza vaccine last October, and had a tetanus shot two years ago when she cut her arm on a piece of metal. Significant Family History: One brothers with hypertension, dx at age 50. She has one son in her 20s, healthy, living at home. Lifestyle: She is a secretary, lives with her husband and son in a nice neighborhood with a low crime rate. She belongs to a local YMCA and says she goes there 4 to 5 days a week to exercise. She has a primary care nurse practitioner provider and goes for her yearly checkups and when she is sick. She has a pap smear done yearly and had her last mammogram a couple months ago. She has a healthy diet and eating pattern. She has a good support system composed of family and friends. Review of Systems: General: Pleasant 46-year-old female sitting in chair talking comfortably. Does not appear to be anxious at this time. Good historian Reference Ball, J. W., Dains, J. E., Flynn, J. A., Solomon, B. S., & Stewart, R. W. (2015). Seidel's guide to physical examination (8th ed.). St. Louis, MO: Elsevier Mosby. Healthline. (2015). Ankle sprain. Retrieved from http://www.healthline.com/health/ankle-sprain#Overview1 Lowth. M. (2016). Ankle fractures. Retrieved from http://patient.info/doctor/ankle-fractures Ortho Info. (2010). Achilles tendinitis. Retrieved from http://orthoinfo.aaos.org/topic.cfm?topic=a00147 Orthopod. (2016). Peroneal tendon subluxation. Retrieved from http://eorthopod.com/peroneal-tendon-subluxation/ Reuss, B., L. (2015). Calcaneofibular ligament injury clinical presentation. Retrieved from http://emedicine.medscape.com/article/85526-clinical

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