NR509 Tina jones (T.J) Week 3 SOAP Note

itials: TJ Age: 28 Gender: Female Height Weight BP HR RR Temp SPO2 Pain Allergies 170cm 88kg 139/ 87 82 16 98.9F 99% Medication: Penicillin (rash/ hives) Food: none Environment: Cats, dust (asthma flares up, itchy, watery eyes, sneezing) History of Present Illness (HPI) Chief Complaint (CC) Headache CC is a BRIEF statement identifying why the patient is here - in the patient’s own words - for instance "headache", NOT "bad headache for 3 days”. Sometimes a patient has more than one complaint. For example: If the patient presents with cough and sore throat, identify which is the CC and which may be an associated symptom Onset 5 days ago Location Pain is located at the crown and back of head. Duration Intermittent- daily-lasts for 1-2hrs per episode. Characteristics Dull headache, non- radiating, associated with neck pain Aggravating Factors Movement of head Relieving Factors Tylenol- improved pain to 3/10 ,rest Treatment No other treatment Current Medications: Include dosage, frequency, length of time used and reason for use; also include OTC or homeopathic products. Medication (Rx, OTC, or Homeopathic) Dosage Frequency Length of Time Used Reason for Use Proventil 2 puffs PRN for asthma PRN Rescue inhaler for asthma exacerbation Flovent Patient unaware of exact dosage BID Daily Mainenence for Asthma Tylenol 2- regular strength tabs Once a day Once a day for 5 days For headache Advil 200mg PRN PRN For menstrual cramps N/A Click or tap here to enter text. Click or tap here to enter text. Click or tap here to enter text. Click or tap here to enter text. Past Medical History (PMHx) – Includes but not limited to immunization status (note date of last tetanus for all adults), past major illnesses, hospitalizations, and surgeries. Depending on the CC, more info may be needed. S