NR_509 Week 6 SOAP note

SOAP Note Template Initials: D.R. Age: 8 years old Gender: Male Height Weight BP HR RR Temp SPO2 Pain Allergies 127 cm 40.9 kg 120/ 76 100 28 37.2 C 96% Medication: No known drug allergies Food: No known food allergies Environment: No known environmental allergies History of Present Illness (HPI) Chief Complaint (CC) “I have been coughing a lot” 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 Started 5 days ago Location Throat and right ear Duration Throat pain x5 days and ear pain x1 day Characteristics Productive cough every couple of minutes with clear sputum. Describes his cough as “gurgly and watery” Cough keeps the patient up at night. Cough is accompanied by a sore throat, right ear pain and worsening rhinorrhea with clear discharge Aggravating Factors Worsens at 2100 every night. Exposed to second hand smoke by his father who smokes a cigar in the house multiple times a week. Relieving Factors Temporary relief with “spoonful of purple cough medicine” Treatment Patient’s mother has been giving the patient a “spoonful of purple cough medicine” with temporary relief. The patient has tried resting and drinking water without relief, the cough “stays the same” 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 Antitussive “One spoonful” by mouth with or without food As needed for cough per age/weight dosage on manufacturer package 1 day Cough Multivitamin One gummy by mouth with or without food Daily Unknown Supplement 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 Click or tap here to enter Click or tap here Click or tap here to enter text. S: Subjective Information the patient or patient representative told you enter text. text. 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, hospitalizations, and surgeries. Depending on the CC, more info may be needed. Diagnosed and treated with antibiotic therapy for pneumonia last year by an urgent care clinic. At the age of 2 the patient had “a lot” of recurrent ear infections. Patient takes a daily gummy multivitamin but when his mom is not looking he “sneaks a few extra.” Denies surgical history, broken bones, or recent hospitilizations. Denies ear surgery or ear tubes. Immunizations up to date with the exception of the influenza vaccine. Immunizations: Hepatitis A:2 dose series completed at 15 months, Hepatitis B: 3-dose series completed at 6 months, Pneumococcal: 4-dose series completed at 15 months, DTaP: 5-dose series completed at age 6, MMR: 2- dose series completed at 6 years, Polio: 4-dose series completed at 6 years old. The patient’s mother takes him to regular doctors appointments where he receives his vaccinations. Had epistaxis once when the patient got hit on the nose by a ball during recess. Patient was sick a couple of months ago with an upset stomach that resolved on it’s own “pretty fast.” 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. Third grade student in Ms. Saint-Jean’s class who likes school but bores easily when the homework is too easy. Lives with his mom (who is a stenographer), dad, Abuelo (maternal grandfather), Abuela (maternal grandmother) and no siblings. Primarily English speaking household with some Spanish spoken intermittently. The patient likes to play video games, read, write stories, rides his skateboard and plays with his friend Tony. The patient wears a helmet each time he rides his skateboard. There are no pets at home. The patients father smokes cigars in the home a couple times a week. The mother asks the father to move outside with his cigar. Reports drinking plenty of water a day due to his Abuela (maternal grandmother) making sure he drinks enough water. Uses seatbelts consistently and has working smoke detectors in his home. Patient missed 2 weeks of school last year when he was diagnosed with pneumonia. 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. Mother-Type 2 diabetic, HTN, Hypercholesterolemia, spinal stenosis and obesity. Father-HTN, Hypercholesterolemia, childhood asthma and is a cigar smoker in the house. Maternal grandmother (living)-Type 2 diabetic, HTN. Maternal grandfather-Smoker and eczema. Paternal grandmother-Died in a car accident when the patient was very young. Paternal grandfather-No known history