NURS 612 Comprehensive Assessment SOAP NOTE.

NURS 612 Comprehensive Assessment SOAP NOTE.S.O.A.P. Note Template CASE ID# Shadow Health Subjective Objective Assessment (diagnosis [primary and differential diagnosis]) Plan (treatment, education, and follow up plan) Chief Complaint What brought you here today…(eg. headache) “I came in because I’m required to have a recent physical exam for the health insurance at my new job” History of Present Illness Chronological order of events, state of health before onset of CC, must include OLDCARTS in paragraph form Onset Mrs. Jones expresses that she recently got a new job and she needs to obtain a pre-employment physical prior to being able to start work. Her last visit to a healthcare facility was 4 months ago where she received her annual gynecological exam. Ms. Jones states that the gynecologist diagnosed her with PCOS and prescribed her a oral contraceptive called YAZ and she is tolerating it well. She has type 2 diabetes and takes metformin for this. She controls her diabetes by medication, exercise and diet. She recently started the metformin 5 months ago. She has had no side effects at this time. She states that at this time she is happy and is excited about starting her new job. Her last pap smear was 4 months ago. She had her last eye exam 3 months ago and her last dental exam 5 months ago. PPD negative 2 years ago. She has smoke detectors in her home, she wears a seatbelt in her car and wears sunscreen when she is outside in the soon. She owns a gun that was once her dads but it is locked up in her parent’s room at this time. 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 Tetanus booster was received within the last year. Influenza is not current at this time. HPV has not been received. She states she is up to date on all childhood immunizations and received the meningococcal vaccine when she was in college. Allergies: cats, and dust. She gets a runny nose, itchy and swollen asthma and worsening asthma symptoms. Penicillin she gets a rash. She denies any allergies to latex or food. Ms. Jones was diagnosed with asthma at the age of 2 ½. She uses a n albuterol inhaler for her asthma when she is around cats or dust and has a flare. Her last asthma attack was three months ago and she was able to resolve this with her inhaler. She was hospitalized last in high school for asthma but states she was never intubated. Diagnosed with type 2 diabetes at age of 24 years old. She began metformin 5 months ago. She checks her blood sugar once daily every morning and her sugars average around 90. She denies any surgeries. Her menarche started at age 11. She experienced sexual activity for the first time at age 18 in which she is interested in men. She has never been pregnant and she is not currently sexually active with her current boyfriend. She plans to use condoms when these does occur. She was tested for HIV/AIDS 4 months ago at gynecological apt. She had her last period 2 weeks ago. She was diagnosed with PCOS 4 months ago. For these past 4 months her cycles have been regularly occurring every four weeks and last 5 days with moderate bleeding. Current Medications: • Fluticasonate Propionate: 110mcg 2 puffs BID( last dose: this am) • Metformin: 850mg PO BID (last dose this am) • YAZ: PO QD (last dose this am) • Albuterol: 90 mcg/spray 2 puffs q4h prn (last dose three months ago) • Acetaminophen: 800-1000mg PO (headaches) • Ibuprofen 600mg PO TID PRN (menstrual cramps last dose 3 weeks ago)