NSG 6435 Soap note week 4 GRADED A
SOAP NOTE
Name: SH Date: 9/10/19 Time: 1015
Age: 8 Sex: FEMALE
SUBJECTIVE
CC: “ My daughter has thrown up once yesterday and complaining of abdominal pain since yesterday, she
couldn’t go to school today”
HPI: Patient is brought in by mother with c/o nausea and vomiting x 1 and abdominal pain since the
previous day. Patient and mother denies any new food intake. Patient is complaining of generalized
abdominal pain.
Medications: None
PMH:None
Allergies: None
Medication Intolerances:: None
Chronic Illnesses/Major traumas: None
Hospitalizations/Surgeries: None
Family History
Mother denied any hx of of psychiatric disease. Mother has diabetes and father is not in the picture.
Social History
Patient lives at home with mother and grandmother. Grandmother smokes cigarettes and mother denies
any smoking
ROS
General Cardiovascular
Mother denies Weight change, fatigue, fever, Mother denies Chest pain, palpitations, PND,
chills, night sweats, energy level orthopnea, edema
Skin Respiratory
This study source was downloaded by 100000815611969 from CourseHero.com on 11-09-2022 23:37:20 GMT -06:00
https://www.coursehero.com/file/49183003/NSG-6435-Soap-note-week-4doc/
SOAP NOTE
Name: SH Date: 9/10/19 Time: 1015
Age: 8 Sex: FEMALE
SUBJECTIVE
CC: “ My daughter has thrown up once yesterday and complaining of abdominal pain since yesterday, she
couldn’t go to school today”
HPI: Patient is brought in by mother with c/o nausea and vomiting x 1 and abdominal pain since the
previous day. Patient and mother denies any new food intake. Patient is complaining of generalized
abdominal pain.
Medications: None
PMH:None
Allergies: None
Medication Intolerances:: None
Chronic Illnesses/Major traumas: None
Hospitalizations/Surgeries: None
Family History
Mother denied any hx of of psychiatric disease. Mother has diabetes and father is not in the picture.
Social History
Patient lives at home with mother and grandmother. Grandmother smokes cigarettes and mother denies
any smoking
ROS
General Cardiovascular
Mother denies Weight change, fatigue, fever, Mother denies Chest pain, palpitations, PND,
chills, night sweats, energy level orthopnea, edema
Skin Respiratory
This study source was downloaded by 100000815611969 from CourseHero.com on 11-09-2022 23:37:20 GMT -06:00
https://www.coursehero.com/file/49183003/NSG-6435-Soap-note-week-4doc/
