NR 509 SOAP motor vehicle accident 2021 ANSWERED

SOAP Note Template Initials: T.J Age: 28 Gender: Female Height Weight BP HR RR Temp SPO2 Pain Rating Allergies (and reaction) 170 cm 88kg 139/ 87 82 16 98.9 99% Medication: none Food: none Environment: cats and dusts (itchy eyes, sneezing, and wheezing) History of Present Illness (HPI) Chief Complaint (CC) Headache and neck pain s/p MVA Patient came in for concerns of headache and neck stiffness s/p MVA one week ago. Her symptoms started two days ago. Complains of headache 3/10 dull ache and neck stiffness. No visible head, neck or face injury noted. Cranial nerves are intact. Gait and balance steady. Able to perform full range of motion. For pain management she only used Tylenol daily. Onset One week ago and symptoms began two days after the accident Location Head and neck Duration Two days Characteristics Neck stiffness and dull headache. Reports “headache pain in crown and back of head.” Aggravating Factors Reports, no triggering factors but states that “comes during the day.” Reports, pain upon head or neck movement. Relieving Factors Symptoms improves with rest and Tylenol use Treatment Rest and Tylenol. denies home remedies such as heat or cold 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 Tylenol Unsure of the dosage, “Two regular straights” Once a day Two days headache