Summary NU 518 CHA Comprehensive Health Assessment SOAP Note Study Guide latest update with completes solutions

Comprehensive Health Assessment SOAP Note University of South Alabama NU 518-801 Advanced Assessment Elizabeth Berrigan PATIENT INFORMATION Date of Patient Encounter: July 5, 2019 J.C. is a 32-year-old, Caucasian, male. Health Insurance Yes Information Source and Reliability Self; Patient is awake, alert, and oriented x4; Patient’s behavior is appropriate to the situation and appears to be a reliable source. S Subjective CHIEF COMPLAINT “I have been coughing for about 2-3 weeks now …first, it was just a dry cough but now it looks green …Well, I am a fireman and a couple days ago on shift, while going on a medical call, I felt short of breath which is not normal for me.” HISTORY OF PRESENT ILLNESS Patient reports discomfort localized to the anterior portion of the chest. Patient describes the pain as a “constant, dull ache” that occurs when coughing with an “intermittent sharp, stabbing pain” anytime he takes a deep breath. The patient rates the discomfort as a 6 on a scale of 1 to 10. Patient reports the onset of symptoms began approximately 2-3 weeks ago, with the cough being consistent throughout the day. Patient reports lack of sleep over the last couple of days due to 24-hour shift work as a fireman. Patients reports increased chest discomfort and shortness of breath during physical exertion. Patient reports feeling tired and decreased appetite in addition to the presenting symptoms of cough and shortness of breath. Patient reports increasing fluid intake and hot showers, and taking an over-the-counter antihistamine and cough/congestion medication, with only mild relief of his cough and no relief of shortness of breath. Patient reports family history of myasthenia gravis (mother) and congestive heart failure (father); personal occupational history of fireman (11 years) and construction worker (17 years). PAST MEDICAL HISTORY Childhood Illnesses Spinal meningitis (1990), Chicken pox (1992) Adult Illnesses Attention-deficit Disorder (1999); h/o upper respiratory infections Health Maintenance Immunizations Screening Tests Compliant with yearly physicals through the Baton Rouge Fire Department; Childhood vaccinations up-to-date. Flu vaccine yearly. Tuberculin test (2018); Cholesterol panel (2018) Past Hospitalizations Surgeries Spinal meningitis (1990, 4 years old, hospitalized for 4 days); Facial reconstruction surgery x2 (2006); wisdom teeth extraction (2001); vasectomy (2016) Injuries / Accidents multiple facial fractures (2006), surgical repair required; right forearm fracture (2009), no required surgery for repair Current Medication Adderall XR 20 mg once daily (last take: 7/6/19); Mucinex-DM 1200 mg guaifenesin & 60 mg dextromethorphan HBr extended-release 1 tablet every 12 hours (last taken: 7/5/19); Allegra-24 180 mg once daily (last taken: 7/5/19) Allergies No known drug allergies FAMILY HISTORY Paternal Grandfather (deceased, age 69): prostate cancer, HTN, Alzheimer’s disease; cause of death – metastasis to pancreatic cancer Paternal Grandmother (living, age 82): TIA, HTN, impaired hearing Maternal Grandfather (living, age 82): Type 2 DM, HTN, retinopathy, psoriatic arthritis, cluster headaches Maternal Grandmother (living, age 80): HTN, migraines Father (living, age 59): congestive heart failure, HTN, hyperlipidemia Mother (living, age 57): myasthenia gravis, HTN, cluster headaches Wife (age 31): Inappropriate Sinus Tachycardia Daughter (age 11): ADHD, slow growth development Pedigree (Genogram) PERSONAL AND SOCIAL HISTORY Family Structure Patient lives with wife of 2 years, 3 children (biological daughter age 11; step- daughter age 10; step-son age 5), 2 dogs and cat. Educational Level High school graduate Occupational History Currently working as a Baton Rouge Fireman, 11 years; Construction worker, 17 years. Economic Status Income adequate to meet needs and live comfortably Home Conditions 2-story house in the suburbs Spiritual and Culture Information Patient reports no religious affiliation.