Exam (elaborations)
Daniel “Danny” Rivera:NR 509 Week 6 SOAP Note Cough: Spring 2020
- Course
- Institution
Daniel “Danny” Rivera:NR 509 Week 6 SOAP Note Cough: Spring 2020
[Show more]
Seller
Follow
EvaTee
Reviews received
Content preview
Your text here 1SOAP Note Template
S: Subjective
Information the patient or patient representative told you
Initials: D.R. Age: 8 Gender: Male
Height Weight BP HR RR Temp SPO2 Pain Allergies
127cm 40.8kg 120/ 100 28 37.2c 96% Medication: none
76 Food: none
Environment: none
History of Present Illness (HPI)
Chief Complaint (CC) Persistent cough with sore throat, ear pain and fatigue from lack of sleep CC is a BRIEF statement identifying
Onset On the bus on the way to school 5 days ago why the patient is here - in the
Location Throat, chest, right ear patient’s own words - for instance
"headache", NOT "bad headache for 3
Duration 5 days
days”. Sometimes a patient has more
Characteristics “gurgly and watery” than one complaint. For example: If
the patient presents with cough and
Aggravating Factors Night time, activity sore throat, identify which is the CC
Relieving Factors One dose of “purple” medicine of unknown composition this morning “helped and which may be an associated
for a little bit” symptom
Treatment Mother gave one “spoonful of purple cough medicine” of unknown brand or
strength
Current Medications: Include dosage, frequency, length of time used and reason for use; also include OTC or homeopathic products.
Medication Length of Time
Dosage Frequency Reason for Use
(Rx, OTC, or Homeopathic) Used
Gummy Multivitamin One chewable daily continuous To increase vitamin intake not found in
daily diet
Unknown cough medicaine One “spoonful” once Click or tap here For cough
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.
enter text. text. 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.
enter text. text. 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.
enter text. text. 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.
Up-to-date on childhood immunizations, no influenza vaccine this year; no hospitalizations or surgeries; no chronic medical issues have been
diagnosed, but had pneumonia one year ago
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.
Danny enjoys video games and reading, wants to be a director when he “grows up”; has never been a smoker and denies drug or alcohol use. He
is an only child who lives with his parents and grandparents in a 9-year-old single family home with an unfinished basement and working smoke
detectors, and no pets; he always wears his seatbelt.
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 diabets, HTN, hypercholesterolemia, spinal stenosis, obesity
Father: Smoker, HTN, hypercholesterolemia, asthma as a child
Maternal Grandmother: Type 2 diabetes, HTN
Maternal Grandfather: Smoker, eczema
Paternal Grandmother: died in a car accident at 52 years old
Paternal Grandfather: no known history
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
☒Fatigue unable to sleep ☐Itching Click or tap ☐Diplopia Click or tap ☒Earache right ear pain ☐Hoarseness Click or tap here
due to constant cough here to enter text. here to enter text. 3/10 to enter text.
☐Weakness Click or tap ☐Rashes Click or tap ☐Eye Pain Click or tap ☐Tinnitus Click or tap here ☐Oral Ulcers Click or tap here
here to enter text. here to enter text. here to enter text. to enter text. to enter text.
☐Fever/Chills Click or tap ☐Nail Changes Click ☐Eye redness Click or ☐Epistaxis Click or tap ☒Sore Throat pain 2/10 with
here to enter text. or tap here to enter tap here to enter text. here to enter text. coughing
☒Weight Gain gained text. ☐Vision changes Click or ☐Vertigo Click or tap here ☐Congestion Click or tap here
weight over the summer ☐Skin Color Changes tap here to enter text. to enter text. to enter text.
☐Weight Loss Click or tap Click or tap here to ☐Photophobia Click or ☐Hearing Changes Click ☒Rhinorrhea clear “slimey”
The benefits of buying summaries with Stuvia:
Guaranteed quality through customer reviews
Stuvia customers have reviewed more than 700,000 summaries. This how you know that you are buying the best documents.
Quick and easy check-out
You can quickly pay through credit card or Stuvia-credit for the summaries. There is no membership needed.
Focus on what matters
Your fellow students write the study notes themselves, which is why the documents are always reliable and up-to-date. This ensures you quickly get to the core!
Frequently asked questions
What do I get when I buy this document?
You get a PDF, available immediately after your purchase. The purchased document is accessible anytime, anywhere and indefinitely through your profile.
Satisfaction guarantee: how does it work?
Our satisfaction guarantee ensures that you always find a study document that suits you well. You fill out a form, and our customer service team takes care of the rest.
Who am I buying these notes from?
Stuvia is a marketplace, so you are not buying this document from us, but from seller EvaTee. Stuvia facilitates payment to the seller.
Will I be stuck with a subscription?
No, you only buy these notes for $19.98. You're not tied to anything after your purchase.
Can Stuvia be trusted?
4.6 stars on Google & Trustpilot (+1000 reviews)
53008 documents were sold in the last 30 days
Founded in 2010, the go-to place to buy study notes for 15 years now