NURS 5220 SOAP Template Complete: A.J. is a 15-year-old female

Identifying Information: (initials, age/DOB, gender, reliability) Family Hx: A.J. is a 15-year-old female freshman student gymnast who is a reliable historian. Parents: Dad: HTN- medicated. Mom: has weight issues. Siblings (sister and brother) are both healthy. Paternal grandfather: HTN Personal/Social Hx: Chief Complaint/RFE: No known allergies or medications. Considering vegetarianism. No substance use. Active in gymnastics. Pain in the left leg related to a recent injury during a gymnastics event. Hx Present Illness: (7 Variables but do not list as such) A.J. experienced pain in her previously injured left knee after a dismount from uneven bars during a gymnastic event 3 days ago. Her pain is at night and worsens when she is up and is isolated to the front lateral aspect. A.J. reports having difficult bending her knee when the brace is off. Even with the use of brace and crutches, there has not been any improvement in her pain levels.