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Sick Visit: Management of Endocrine Conditions Results -subjective data

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Sick Visit: Management of Endocrine Conditions Results -subjective data

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Sick Visit: Management of Endocrine Conditions Results -subjective dataSick Visit: Management of Endocrine Conditions Results -subjective dataSick Visit: Management of Endocrine Conditions Results -subjective dataSick Visit: Management of Endocrine Conditions Results -subjective data

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Running2head:2NEUROLOGICAL2SICK2VISIT2SOAP2NOTE

Neurological2Sick2Visit2SOAP2Note

Ugoma2Konkwo

United2States2University,2Department2of2Nursing

MSN2572:2Advanced2Health2and2Physical2Assessment2Across2the2Lifespa

n2Professor2Rebecca2Richmond

June28,22023

This2study2source2was2downloaded2by21000008905867842from2CourseHero.com2on209-25-2024213:18:462GMT2-
05:00

https://www.coursehero.com/file/209638127/Neuro-Sick-Visit-SOAP-Notepdf/

, NEUROLOGICAL2SICK2VISIT2SOAP2NOT 2
E

Neurological2Sick2Visit

ID:2A.D.,2DOB:26/2/1990,2332year-

old2African2American2female2presented2to2the2clinic2today.2Arrived2unaccompanied2and2is2a2reliable2hi

storian.

Subjective:

CC:2“I2have2had2a2headache2for2about242days.”

HPI:2A.D.2presents2to2the2clinic2complaining2of2a2headache2that2started242days2ago.2The2patient2endorses

2attempting2to2concentrate2on2a2task2as2being2an2aggravating2factor.2The2patient2characterizes2the2pain2as2

being2“dull”2and2“aching”2and2located2mostly2in2her2forehead2region2with2a2pain2rating2of27/10.2Reports2

alleviating2factors2to2be2rest2and2Tylenol2which2provides2temporary2relief2and2have2been2the2only2treatm

ents2she2has2tried.2She2denies2having2any2recent2head2or2neck2trauma.2Patient2denies2having2food2or2drug2

allergies.2She2appears2to2be2a2reliable2historian2and2an2otherwise2healthy2individual2with2no2relevant2med

ical2history.2The2patient’s2last2office2visit2was272months2ago2for2an2annual2wellness2check.2There2was2no2

acute2distress2or2illnesses2noted2at2that2time.

Past2Medical2History:2Denies

Past2Medical2Procedures:2Denies

Medications:2Acetaminophen2650mg2every24-62hours2as2needed2for2pain

Allergies:2Denies

Immunizations:2Reports2being2up2to2date2on2all2vaccinations

Family2History:

Mother:2Living,2562years2old,2None

Father:2Living,2592years2old,2None

Maternal2Grandmother:2Deceased2at2752years2old2of2a2stroke
This2study2source2was2downloaded2by21000008905867842from2CourseHero.com2on209-25-2024213:18:462GMT2-
05:00

https://www.coursehero.com/file/209638127/Neuro-Sick-Visit-SOAP-Notepdf/

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Uploaded on: September 25, 2024
Number of pages: 9
Written in: 2024/2025
Type: Exam (elaborations)
Contains: Questions & answers

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