Exam (elaborations)
Daniel “Danny” Rivera:NR 509 Week 6 SOAP Note Cough: Spring 2020
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Daniel “Danny” Rivera:NR 509 Week 6 SOAP Note Cough: Spring 2020
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SOAP Note Template Initials : Daniel “Danny” Rivera Age: 8 Gender : Male Height Weight BP HR RR Temp SPO2 Pain Allergies 127cm 40.8kg 120/76 100 28 37.2c 96% 3/10 Medication: none 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 why the patient is here - in the patient’s own words - for instance "headache", NOT "bad headache for 3 days”. Sometimes a patient has more than one complaint. For example: If the patient presents with cough and sore throat, identify which is the CC and which may be an associated symptom Onset On the bus on the way to school 5 days ago Location Throat , chest, right ear Duration 5 days Characteristics “gurgly and watery” Aggravating Factors Night time , activity Relieving Factors One dose of “purple” medicine of unknown composition this morning “helped for a little bit” 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 (Rx, OTC, or Homeopathic) Dosage Frequency Length of Time Used Reason for Use 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 to enter text. For cough Click or tap here to enter text. Click or tap here to enter text. Click or tap here to enter text. Click or tap here to enter text. Click or tap here to enter text. Click or tap here to enter text. Click or tap here to enter text. Click or tap here to enter text. Click or tap here to enter text. Click or tap here to enter text. Click or tap here to enter text. Click or tap here to enter text. Click or tap here to enter text. Click or tap here to enter text. Click or tap here to enter text. S: Subjective Information the p atient or patient representative told you Past Medical History (PMH x) – 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 hospitalizati ons 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 h obbies, family status, tobacco and alcohol use, and any o ther pertinent data. Include health promotion such as use seat belts all the time or working smoke detectors in the house. Danny e njoys 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. Inclu de grandchildren if pertinen t. Mother: Type 2 diabets , HTN, hypercholesterolemia, spinal stenosis, obesity Father: Smoker, HTN, hyper cholesterolemia , asthma as a child Maternal Grandmother: Type 2 diabetes, HTN Maternal Grandfather: Smoker, eczema Paternal Grandmother: died in a c ar 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 due to constant cough ☐Weakness Click or tap here to enter text. ☐Fever/Chills Click or tap here to enter text. ☒Weight Gain gained weight over the summer ☐Itching Click or tap here to enter text. ☐Rashes Click or tap here to enter text. ☐Nail Changes Click or tap here to enter text. ☐Diplopia Click or tap here to enter text. ☐Eye Pain Click or tap here to enter text. ☐Eye redness Click or tap here to enter text. ☐Vision changes Click or tap here to enter text. ☒Earache right ear pain 3/10 ☐Tinnitus Click or tap here to enter text. ☐Epistaxis Click or tap here to enter text. ☐Vertigo Click or tap here to enter text. ☐Hoarseness Click or tap here to enter text. ☐Oral Ulcers Click or tap here to enter text. ☒Sore Throat pain 2/10 with coughing ☐Congestion Click or tap here to enter text.
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