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NURS 5120 Comprehensive SOAP Note week 2 graded A
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NURS 5120 Comprehensive SOAP Note week 2 graded A
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NURS 5120 Comprehensive SOAP Noteweek 2 graded A NURS 5120 Comprehensive SOAP Note 5210 week 2
In partial fulfillment of the requirements of NURS 5120-436 Adult-Gerontology Assessment
Course Faculty: Jennifer Robb, MSN, ANCP, ANCC March 3, 2021 SOAP 2
SOAP Note Form
S/ Identifying Information: (initials,
age/DOB, gender, reliability)Family Hx:
This is Mrs. C.W., a 64-year-old Caucasian female. She is a reliable historian.Mrs. C.W. was an only child; her parents are both decreased. She reports that she never knew her grandparents: “They died before I was born”. Her parents were both only children. Her father died when she was
nine years old of a heart attack: “I don’t know his health history except he
drank alcohol daily and smoked cigarettes; I think that was damaging to h
heart.” Her mother died " in her 90’s” from pancreatic cancer. Her mother
also had several strokes.
Personal/Social Hx:
Chief Complaint/RFE:
Mrs. C.W. reports she has been married for 42 years. She denies using
tobacco products, drinking alcohol, or using recreational drugs.“I have had a dry cough”
Hx Present Illness: (7 Variables
but do not list as such)
Mrs. C.W. reports that the onset of her cough was “3 or 4 days ago.” The location of her pain is “[my] chest and throat” She describes the character of her cough as “irritating to me and to others”. Mrs. C.W. reports that her other symptoms include coughing up phlegm; she also states, “I didn’t’ realize it, but I have a fever when I came in today.” She reports her cough is aggravated in the morning--“just when [I] wake up”. She reports the cough is only relived “ the day goes on”. She denies having any contacts with people who might be sick. She rates the pain associated with her cough at a 4 or 5 out of 10 on 0-10 scale. She reports taking cough drops to help relieve her cough.
CURRENT HEALTH
Medications:
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