Exam (elaborations)
NURS 5220-Module 3 SOAP note Form-1-latest-
- Course
- NURS 5220
- Institution
- University Of Texas - Arlington
NURS 5220-Module 3 SOAP note Form-1-latest-
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NURS 5 220-Module 3 SOAP note Form -1-latest -2023 -2024 SOAP Note Form S/ Identifying Information: (initials, age/DOB, gender, reliability) Family Hx: A.J 15 years old Female Patient good historian *Patient reports that her father has hypertension which he controls with meds. *Patient reports her mom and sister have weight issues. *Patient mom reports no mental health concerns, no diabetes, no exposure to communicable diseases, no recent travel outside the U.S, no smokers, no stroke, no lung disease, no asthma, no blood disorders, no seizures, and no headaches within the family. *Patient mom reports that the paternal grandfather has hypertension. Personal/Social Hx: Chief Complaint/RFE: A.J. is a gymnast who trains five days a week for one and a half hour per session. Patient reports she enjoys running recreationally. Patient reports no other involvement in clubs or interest. Left leg pain Hx Present Illness: (7 Variables but do not list as such) A.J is a 15 -year-old female who presents to the office with a chief complaint of left leg pain, which started 3 days ago at her gymnastic competition following an improper landing. A.J previously suffered an injury to the same area; no medical care was sou ght out for the injury. Date of last incident not reported. Patient reports the pain is localized to the front part of her knee, and the pain is not improved despite interventions such as application of a brace, use of crutches, and receiving Motrin 600mg 3-4 times a day. Patient reports pain is worse at night and has difficulty bending the affected knee when the brace is not on. CURRENT HEALTH Medications: Patient Mom reports giving patient Motrin 600mg 3-4 times per day for 3 days. No other medications reported. Allergies : Patient reports no known allergies. Last PE & Screenings: A. J reports her last PCP visit was at age 11, her vision and hearing were last checked at that visit. A.J has not been seen by a primary care physician since her last visit. Immunization Status: Per patient mom A. J last received her immunization vaccinations as well as one HPV vaccine and one Hepatitis A vaccine at age 11 and is currently up to date with immunizations. A.J receives the flu shot annually. LMP & Birth Control (if applicable ) A.J reports having monthly periods since the age of 12, with the last menstrual period being within the past month. A.J denies birth control use and has not seen a GYN. PMH Illnesses & Trauma: Patient reports no significant illness or trauma. Hospitalizations/Surgeries : No reports of surgeries or hospitalizations. OB Hx/Sexual Hx: Patient denies any sexual encounters. Patient states she likes boys but does not have a boyfriend. Emotional/Psych Hx: Patient reports no mental health concerns, however, reports recent sadness and per patient mom patient is with a shortened temper following the recent injury. REVIEW OF SYSTEMS General Nutrition - A. J reports eating a healthy diet but is thinking about becoming a vegetarian. Patient mom with concern of lack of protein in A.J current diet. However, patient BMI concerning for obesity. Skin/Hair/Nails - I will ask the patient if she has any concerns regarding her hair/skin/nails. HEENT - A.J reports having no eye or vision issues, no hearing or ear pain, no headaches, no nasal drainage, no nosebleeds, no sore throat or voice changes, no teeth or mouth issues, and no issues with taste or smell. Breasts - I will ask the patient if she has any concerns related to the size, development, or appearance of her breasts. Respiratory - I will ask the patient if she ever experiences shortness of breath or dyspnea on exertion. CV/peripheral vascular – Patient states there are no issues with her heart, no palpitations, no chest pain, no syncope. GI – A.J reports no abdominal pain, no constipation or diarrhea, and reports no blood in her stool. GU- A.J reports no issues with voiding. MSK - A.J denies any other musculoskeletal concerns other than her left knee. Psych - A.J reports recent sadness following the injury and expressed her frustration when she compares her agileness and limberness to her competitors. Neuro – Patient reports no syncope Lymph/Heme/Endocrine O/ Physical Exam : T: 37.0 P: 88 R: 16 BP: 110/72 HT: 5”6 WT: 70.5 kg BMI: 25.1 Genera l- Not obtained Skin- Not obtained Head - Not obtained EENT - Not obtained Neck - Not obtained Breasts/Chest - Not obtainedThe benefits of buying summaries with Stuvia:
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