NSG6020_Week_6_SOAP_Note_

NSG6020_Week_6_SOAP_Note_ Age: 60 Sex: Female SUBJECTIVE CC: “I have pain in my right leg.” Reason given by the patient for seeking medical care “in quotes” HPI: Patient states it began 3 days ago. The ...

NSG6020_Week_6_SOAP_Note_ Age: 60 Sex: Female SUBJECTIVE CC: “I have pain in my right leg.” Reason given by the patient for seeking medical care “in quotes” HPI: Patient states it began 3 days ago. The pain is in the right lower leg and she states that it also feels tight. The pain is a 7/10. Describe the course of the patient’s illness, including when it began, character of symptoms, location where the symptoms began, aggravating or alleviating factors; pertinent positives and negatives, other related diseases, past illnesses, surgeries or past diagnostic testing related to present illness. Medications: (list with reason for med ) None PMH No past medical history. Allergies: NKA Medication Intolerances: Denies Chronic Illnesses/Major traumas Denies Hospitalizations/Surgeries Denies “Have you every been told that you have: Diabetes, HTN, peptic ulcer disease, asthma, lung disease, heart disease, cancer, TB, thyroid problems or kidney disease or psychiatric diagnosis.” Family History Does your mother, father or siblings have any medical or psychiatric illnesses? Anyone diagnosed with: lung disease, heart disease, htn, cancer, TB, DM, or kidney disease. Mother had HTN, Father has CHF. Social History College graduate, married. Denies substance abuse. Education level, occupational history, current living situation/partner/marital status, substance use/abuse, ETOH, tobacco, marijuana. Safety status Denies ETOH, tobacco, marijuana. ROS General Weight change, fatigue, fever, chills, night sweats, energy level Denies weight change, fatigue, fever, chills, night sweats. Cardiovascular Chest pain, palpitations, PND, orthopnea, edema Denies chest pain, no palpitations, no orthopnea. Skin Delayed healing, rashes, bruising, bleeding or skin discolorations, any changes in lesions or moles Denies delayed healing, rashes, bruising, bleeding or skin discolorations, any changes or lesions or moles. Respiratory Cough, wheezing, hemoptysis, dyspnea, pneumonia hx, TB No cough, wheezing, hemoptysis, dyspnea, pneumonia. Eyes Corrective lenses, blurring, visual changes of any kind Does not wear glasses, no blurry vision, no visual changes of any kind. Gastrointestinal Abdominal pain, N/V/D, constipation, hepatitis, hemorrhoids, eating disorders, ulcers, black tarry stools No abdominal pain, N/V/D, constipation, hepatitis, hemorrhoids, eating disorders, ulcers, black tarry stools. Ears Ear pain, hearing loss, ringing in ears, discharge Denies ear pain, hearing loss, ringing in ears, discharge. Genitourinary/Gynecological Urgency, frequency burning, change in color of urine Denies frequency, burning, change in color of urine. Contraception, sexual activity, STDS Fe: last pap, breast, mammo, menstrual complaints, vaginal discharge, pregnancy hx Does not use contraception. Is sexually active with her husband. Denies STDs. Last pap was 2 years ago which was negative. Does not have menstrual periods. Denies pregnancy or vaginal discharge. Male: prostate, PSA, urinary complaints Nose/Mouth/Throat Sinus problems, dysphagia, nose bleeds or discharge, dental disease, hoarseness, throat pain Denies sinus problems, dysphagia, nose bleeds or discharge, dental disease, hoarseness, throat pain. Musculoskeletal Back pain, joint swelling, stiffness or pain, fracture hx, osteoporosis Denies back pain, there is swelling in the right lower leg with tightness and pain. No fracture or osteoporosis. Breast Admits to doing SBE monthly, denies any bumps or changes. SBE, lumps, bumps or changes Neurological Denies syncope, seizures, transient paralysis, weakness, paresthesias, black out spells. Syncope, seizures, transient paralysis, weakness, paresthesias, black out spells Heme/Lymph/Endo HIV status is negative. Denies bruising, blood transfusion hx, night sweats, swollen glands, increase thirst, increase hunger, cold or heat intolerance. HIV status, bruising, blood transfusion hx, night sweats, swollen glands, increase thirst, increase hunger, cold or heat intolerance Psychiatric Denies depression, anxiety, sleep issues, suicidal ideation/attempt. Depression, anxiety, sleeping difficulties, suicidal ideation/attempts, previous dx