NR 509 Week 6 iHuman SOAP_Note
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$20.00
| Institution | NR 509 Advanced Physical Assessment |
| Contributor | Bradley |
SOAP Note Template
| S: Subjective Information the patient or patient representative told you | |||||||||||||||
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Initials: CR | Age: 65 | Gender: Female |
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Height | Weight | BP | HR | RR | Temp | SPO2 | Pain Rating | Allergies (and reaction) No known drug allergies |
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66” | 130 | 136/ 80 right arm | 88 | 16 | 98.6 | 96 room air |
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| Medication: NKDA Food: No known food allergies Environment: No known environment allergies |
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History of Present Illness (HPI) |
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Chief Complaint (CC) | My back hurts really hurts | 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 |
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Onset | Two days Acute | |||||||||||||||
Location | Lower back | |||||||||||||||
Duration | Two days | |||||||||||||||
Characteristics | Sharp pain | |||||||||||||||
Aggravating Factors | Pain is worse with walking, rolling over in bed, sleeping or bending. | |||||||||||||||
Relieving Factors | Denies any relieving factors | |||||||||||||||
Treatment | Denies any treatment at this time | |||||||||||||||
Current Medications: Include dosage, frequency, length of time used and reason for use; also include OTC or homeopathic products. |
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Medication (Rx, OTC, or Homeopathic) | Dosage | Frequency | Length of Time Used | Reason for Use |
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Fluticasone/salmetrol 250/50 x | 250/50 | I puff BID | 1 + year | Asthma |
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HCTZ | 12.5 | DAILY | 1 + year | HTN |
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Alendronate | 70 mg | q Monday | 1 + year | Osteoporosis |
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Calcium with Vitamin D | Multivitamin | Daily | 1 + year | osteoporosis |
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Prednisone | 60x 3 days; 30 x 3 days then continue reduction | Until complete | With asthma exacerbation | Asthma |
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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. |
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| Instituition / Term | |
| Term | Year 2022 |
| Institution | NR 509 Advanced Physical Assessment |
| Contributor | Bradley |
