Exam (elaborations)
NU 518-Comprehensive Health Assessment SOAP Jennifer Collier-V2-2023
- Course
- NU 518 (NU518)
- Institution
- University Of South Alabama
NU 518-Comprehensive Health Assessment SOAP Jennifer Collier-V2-2023
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1 NU 518 -Comprehensive Health Assessment SOAP Jennifer Collier -V2-2023 S – SUBJECTIVE DATA Patient Information ● Age: 35 y/o ● Sex: Male ● Race: Caucasian ● Insurance: No Source of information : The patient is a reliable historian. Chief complaint “I have knots all over my body.” History of present illness -Numerous fatty lumps noted between the skin and underlying muscle layer throughout body. ● Location: Torso area, thorax region, upper back, bilateral shoulders, abdomen area, bilaterally throughout the lower extremities and bilaterally throughout the upper extremities more predominantly on forearms. ● Quality: “pinching” sensation with palpation ● Quantity: Discomfort from palpation rates a 2 on a 1 to 10 scale ● Timing: first known fatty lump found on posterior side of RLE approximately 3 years ago; fatty lumps have since continued to spontaneously develop throughout identified body areas at unknown rate ● Setting or context at onset: none reported ● Aggravating factors: none reported ● Relieving factors: none reported ● Associated manifestations: none reported ● Self-treatment: patient denies any self-treatment remedies ● Significant past medical history: o Mother : history of fatty lipomas o Father : history of fatty lipomas Past medical history ● Current Medications: No prescribed medications; OTC medication: Men’s multivitamin 1 tablet PO daily -supplement (intermittently) ● Allergies: None ● Childhood illnesses : Chronic ear infections ages 2 month thru age 10; Attention deficient disorder diagnosed age 9. ● Adult illnesses: Kidney stones August 2018 ● Hospitalizations/Surgeries: Admitted to hospital in August 2018 for 24 -hour observation due to low heart rate and kidney stones. 6 sets of tympanostomy tubes from years 1985 - 1995 2 ● Injuries/Accidents : Patient reports R. ankle fracture while playing football in 2003; Head laceration from altercation in 2002. ● Health maintenance: Yearly physicals for work, annual eye exams and regular dental cleaningsThe benefits of buying summaries with Stuvia:
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