NR 509 Week 5 Soap Note (NR509)

Exam (elaborations) NR 509 Week 5 Soap Note (NR509) SOAP NOTES TEMPLATE S: Subjective Information the patient or patient representative told you. Initials: EP Age: 78 Gender: Female Height: 5’2” Weight: 120 lbs BP: 110/70 HR:92 Temp: 37.0 C SPO2: 99 RR: 16 Pain (1-10): 6 Allergies: Medication: NKDA Food: none Environment: Latex—“itchy rash” History of Present Illness (HPI) Chief Complaint (CC): “pain in my belly” and difficulty going to the bathroom Onset: Constipation 5 days ago with the exception of an episode of was watery diarrhea 3 days ago Location: “low in abdomen” Duration: constant x 5 days Characteristics: dull “crampy” feeling Aggravating Factors: eating causes bloating and increased pain, physical activity Relieving Factors: resting helps a little Treatment: sips of warm water which did not work NR 509 Week 5 Soap Note SOAP NOTES TEMPLATE States feeling like she needs to “rest more often” due to the pain. Current Medications Medication Dosage Frequency Length of Time Used Reason for Use Accupril 10mg Daily Unknown hypertension Past Medical History (PMHx)- Mrs. Park is a pleasant 78-year-old Korean female. She has a history of hypertension and a surgical history that is significant for cholecystectomy and one cesarean section. She is gravida three para three with two living children and one still birth by cesarean section. Her only hospitalizations were for her cholecystectomy, cesarean section and for the births of her other two children. She is unsure of date of last tetanus, immunizations up to date, has not had flu shot this year. Her last colonoscopy was 10 years ago, and the results were normal. She denies a history of constipation. She does not take vitamins or herbal supplements. She denies taking any pain medication. She does not check her blood pressure at home. Social History (SocHx)- Mrs. Park was married for fifty years, her husband, Shin died 6 years ago. She is now seeing a “gentleman friend” and is sexually active. She denies the use of contraceptives and state she has never had a sexually transmitted disease. She denies vaginal or anal intercourse but reports that they “touch and have oral sex”. She denies illicit drug use of any kind. She has never smoked and drinks one glass of dry white wine on Sundays only. She stays active with water aerobics, Pilates, walking with friends, and gardening. She lives with her daughter’s family and usually helps with household chores. Family History (FamHx)- Mother: deceased at age 88, cause of death CVA with known history of HTN, DM II Father: deceased at age 82, passed away in his sleep with known history of HTN, hypercholesterolemia, obesity Maternal grandmother: history of DM II Maternal grandfather: Died from heart attack with known history of coronary artery disease Paternal grandmother: HTN, died from cancer Paternal grandfather: died in his sleep without any known medical history Siblings: SOAP NOTES TEMPLATE Brother, 80: HTN, hypercholesterolemia, slow growing prostate CA Brother, 81: HTN Son: Healthy age 48 Daughter: Healthy age 46 Review of Systems (ROS): Address all body systems that may help rule in or out a differential diagnosis Check the box next to each positive symptom and provide additional details. Constitutional Check if Positive Symptom Details x Fatigue States feeling like she needs to rest more frequently but denies fatigue Weakness Fever/Chills Weight Gain Trouble Sleeping Night Sweats Other Skin: Denies all symptoms Check if Positive Symptom Details Itching Rashes Nail Skin Color Other HEENT: Denies all symptoms Check if Positive Symptom Details Diplopia Eye Pain Eye redness Vision changes Photophobia Eye discharge Eye discharge Earache SOAP NOTES TEMPLATE Tinnitus Vertigo Hearing Changes Hoarseness Sore Throat Congestion Rhinorrhea Other Respiratory: Denies all symptoms Check if Positive Symptom Details Cough Hemoptysis Dyspnea Orthopnea Pain on Inspiration Other Neuro: Denies all symptoms Check if Positive Symptom Details Syncope or Lightheadedness Headache Numbness Tingling Sensation Changes RUE LUE RLE LLE Speech Deficits Other Cardiovascular: Denies all symptoms Check if Positive Symptom Details Chest pain SOB Exercise Intolerance Orthopnea SOAP NOTES TEMPLATE Edema Murmurs Palpitations Faintness OC Changes Claudication PND Other MSK: Denies all symptoms Check if Positive Symptom Details Pain Stiffness Stiffness Crepitus Limited ROM RUE LUE RLE LLE Redness Misalignment Other GI Check if Positive Symptom Details Nausea/Vomiting Denies Dysphasia Denies x Diarrhea Last bowel movement was an episode of watery diarrhea 3 days ago X Appetite Change decreased Heartburn Denies Blood in Stool Denies X Abdominal Pain Dull and cramping X Excessive Flatus Reports more than normal Food Intolerance Denies Rectal Bleeding Denies Other Last colonoscopy 10 years ago, results normal Typically has bowel movements daily, usually soft SOAP NOTES TEMPLATE and formed GU Check if Positive Symptom Details Urgency Denies Dysuria Denies Burning Denies Hematuria Denies Polyuria denies Nocturia denies Incontinence denies Other States slightly less urination than normal but thinks it is due to her “drinking less than normal” PSYCH: Denies all symptoms