NURS 612 Week 5 assignment 5.4

NURS 612 Week 5 assignment 5.4S.O.A.P. Note Template CASE ID# _Week 5 assignment 5.4__________ Subjective Objective Assessment (diagnosis [primary and differential diagnosis]) Plan (treatment, education, and follow up plan) Chief Complaint What brought you here today…(eg. headache) Cough/Congestion. History of Present Illness Chronological order of events, state of health before onset of CC, must include OLDCARTS in paragraph form Onset Well developed middle-age Caucasian female that presents to the clinic with having a cough for a couple of days. The cough is sometimes productive with unknown color and thickness of sputum, specifically at night when the patient lies down. Patient complains of chills during the night, fatigue in her body and generally “run down”. Patient has not been taking any type of medication to alleviate symptoms. Patient has no prescriptions for the use of cough and congestion, patient states that she is not taking any over-the-counter medications at this time. There is chest congestion present. Location Duration Character Aggravating/associated factors Relieving factors Temporal factors – other things going on Severity Past Medical History Adult Illnesses, childhood illnesses, immunizations, surgeries, allergies, current medications Unknown if patient is up-to-date on childhood immunizations. Patient states that she has received the flu shot. Patient states that she does have seasonal allergies. No current medications been taking by prescription or over-the-counter. Family History Include Parents, siblings; grandparents if applicable/known, cause of death, age, pertinent medical illnesses No Lung disease No other general family history given in the chest documentation video. Personal/Social History Education, marital status, occupation, alcohol/drug use, smoking status, sexual history if relevant, exercise, nutrition, religious preference if known Unknown marital status, Unknown sexual status, no illicit drug or alcohol use, previous smoker approximately 20 years ago has not smoked since, Unknown exercise status, Unknown nutritional status, Unknown religious preference, exposed daily to college students on campus. Review of Systems General: + chills, fatigue Hair, Skin, & Nails: - Color change, no hair loss, nails unassessed Head: - head ache, no loss of consciousness Neck: - Pain Eyes: + no acute change in vision Ears: - hearing change, pain, tinnitus, virtigo Nose: - loss of smell, nasal congestion, nasal drainage, nasal pain Mouth & Throat: - pain, dryness, hoarseness, swelling Cardiovascular: - pain, palpitations Respiratory: + cough, + shortness of breath + wheezing - pain Breasts: - pain, Gastrointestinal: unassessed Musculoskeletal: - pain, dislocations, injuries Peripheral: - pain, discoloration, temp change Neurological: - loss of consciousness