Advanced NUR509 Week 4 Physical Assessment Soaps Note well Analysed Revised,Top Rated-

SOAP Note Template S: Subjective Information the patient or patient representative told you Initials: BF Age: 58 Gender: Male Height Weight BP HR RR Temp SPO2 Pain Rating 5’11” 197 lbs 146/ 90 104 98 36.7C 98% RA 1/10 Medication: Codeine (N&V) Food: N/A Environment: N/A History of Present Illness (HPI) Chief Complaint (CC) Chest Pain Onset Earlier this month, has happened three times in the past month. Location Middle of patient’s chest, over his heart, non-radiating. Duration A couple of minutes Characteristics Tight and uncomfortable in middle of Pt chest. Aggravating Factors Seems to worsen with physical activity Relieving Factors Treatment Lying still some offers relief Allergies (and reaction) 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 No medications, just rest. 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 Metoprolol (Lopressor? 100 mg PO Daily 1 year BP Atorvastatin (Lipitor) 20 mg PO Daily HS 1 year Cholesterol lowering medication Omega 3 Fish OIL Not Reported Not Reported Not reported “Good for Cholesterol” 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. 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. 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, Downloaded by Morris Muthii () hospitalizations, and surgeries. Depending on the CC, more info may be needed. Patient reports being up to date on all immunizations and confirms all allergies. Pt denies any previous hospitalizations or surgeries. Patient denies previous diagnosis of angina, CAD, DM, or previous chest pain treatment. Pt positive history for HTN and elevated cholesterol. Reports infrequent BP monitoring at home, reports recent EKG test and annual stress test as “normal”. Social History (Soc Hx) - Includes but not limited to occupation and major hobbies, family status, tobacco and alcohol use, and any other pertinent data. Include health promotion such as use seat belts all the time or working smoke detectors in the house. The patient reports a generally low stress lifestyle, employed at a civil engineering firm in town. Patients diet consists of grilled meats (typically red meat, 4-5 times a week), sandwiches, and vegetables, Pt drinks 1-2 cups of coffee a day, denies tobacco use, reports alcohol use at 2-3 drinks a week, typically in one sitting. Denies soda consumption, drinks 4 glasses of water/day, denies regular exercise routine. Family History (Fam Hx) - Includes but not limited to illnesses with possible genetic predisposition, contagious or chronic illnesses. Reason for death of any deceased first degree relatives should be included. Include parents, grandparents, siblings, and children. Include grandchildren if pertinent. Pt reports family history of heart attack, maternal grandfather deceased from heart attack at young age. Father dies of colon cancer, Mother and Sister have DM, Daughter has asthma, and all family members have elevated BP. Denies family history of Stroke or PE. Review of Systems (ROS): Address all body systems that may help rule in or out a differential diagnosis Check the box next to each positive symptom and provide additional details. Constitutional Skin HEENT Downloaded by Morris Muthii () lOMoARcPSD| lOMoARcPSD| If patient denies all symptoms for this system, check here: ☐ If patient denies all symptoms for this system, check here: ☒ ☐Fatigue Denies ☐Weakness Denies ☐Fever/Chills Denies ☐Weight Gain Denies ☐Weight Loss Denies ☐Trouble Sleeping Denies ☐Night Sweats Denies ☐Other: Click or tap here to enter text. If patient denies all symptoms for this system, check here: ☐ ☐Itching Click or tap here to enter text. ☐Rashes Click or tap here to enter text. ☐Nail Changes Click or tap here to enter text. ☐Skin Color Changes Click or tap here to enter text. ☐Other: Click or tap here to enter text. ☐Diplopia Click or tap here to enter text. ☐Eye Pain Click or tap here to enter text. ☐Eye redness Click or tap here to enter text. ☐Vision changes Click or tap here to enter text. ☐Photophobia Click or tap here to enter text. ☐Eye discharge Click or tap here to enter text. ☐Earache Click or tap here to enter text. ☐Tinnitus Click or tap here to enter text. ☐Epistaxis Click or tap here to enter text. ☐Vertigo Click or tap here to enter text. ☐Hearing Changes Click or tap here to enter text. ☐Hoarseness Click or tap here to enter text. ☐Oral Ulcers Click or tap here to enter text. ☐Sore Throat Click or tap here to enter text. ☐Congestion Click or tap here to enter text. ☐Rhinorrhea Click or tap here to enter text. ☐Other: Click or tap here to enter text. Respiratory If patient denies all symptoms for this system, check here: ☒ Neuro If patient denies all symptoms for this system, check here: ☐ ☐Cough Denies ☐Hemoptysis Denies ☐Dyspnea Denies ☐Wheezing Denies ☐Pain on Inspiration Denies ☐Sputum Production Choose an item. Choose an item. Choose an item. ☐Other: Click or tap here to enter text. MSK Cardiac and Peripheral Vascular If patient denies all symptoms for this system, check here: ☐ ☐Syncope or Lightheadedness Click or tap here to enter text. ☐Headache Click or tap here to enter text. Numbness Click or tap here to enter text. ☐Tingling Click or tap here to enter text. ☐Sensation Changes Choose an item. ☐Speech Deficits Click or tap here to enter text. ☐Other: Click or tap here to enter text. ☒Chest pain In the last month, center chest, several minutes, 5/10 pain ☐SOB Click or tap here to enter text. ☒Exercise Intolerance Pain occurred with yard work/stairs ☐Orthopnea Denies ☐Edema Denies ☐Murmurs Denies ☐Palpitations Denies ☐Faintness Denies ☐Claudications Denies ☐PND Denies ☐Other: Click or tap here to enter text. GI GU PSYCH If patient denies all symptoms for this If patient denies all symptoms If patient denies all symptoms for Downloaded by Morris Muthii () If patient denies all symptom