| SOAP Note Form | |||
| S/ Identifying Information: A.J, 15, F
MIXED UP SOAP NOTE – Nurs 5220 Advanced Health Assessment |
Family Hx: Parents: Dad has a high-stress job and hyper tension, on medications, Mom is a stay at home mom, +weight issues but overall no meds and healthy. Siblings (one in college, girl, +weight issues and overall healthy), brother (senior in high school, is looking at going away to school, healthy). Mom states no mental health concerns in the family, denies diabetes, exposure to communicable diseases, no recent travel outside of the US, no smokers, no stroke, lung disease, or asthma, no blood disorders, seizures, headache. Paternal grandfather with hypertension | ||
| Personal/Social Hx: Has few school friends.
Denies drugs, alcohol or use of illegal substance, no sports enhancing drugs; denies sexual encounters, she likes boys, denies a boyfriend |
|||
| Chief Complaint/RFE: Left leg pain | |||
| Hx Present Illness: (7 Variables but do not list as such)she had left leg injury 3 days ago; previous left knee injury; | |||
| CURRENT HEALTH | |||
| Medications: Motrin 600 mg 3-4 times a day | |||
| Allergies: NKA | |||
| Last PE & Screenings: Previous left knee injury one year ago, no other broken bones to injuries | |||
| Immunization Status: yearly flu shots, and last got immunizations around age 11 and had one HPV and one Hepatitis A immunization at age 11 | |||
| LMP & Birth Control (if applicable): N/a | |||
| PMH | |||
| Illnesses & Trauma: none | |||
| Hospitalizations/Surgeries: never been hospitalized; | |||
| OB Hx/Sexual Hx: regular period; began at 12 years | |||
| Emotional/Psy Hx: concerns with height; often notes that she is taller than other gymnasts and gets frustrated that she is not as limber or agile as her other competitors.no major mental health concerns; short tempered and sad due to the injury | |||
| REVIEW OF SYSTEMS | |||
| General : Negative for fevers, chills, fatigue; weight loss | |||
| Nutrition : eats a healthy diet; wants to become vegetarian; not obese | |||
| Skin/Hair/Nails : negative for itching, burning, rashes; red and sore at the site of injury | |||
| HEENT: denies vision or hearing problems; does not wear glasses or hearing aids; denies nasal drainage, nose bleeds and problems with smell and taste; No sore throat or voice changes, no mouth or teeth issues, and routinely sees a dentist, last visit in the past six months. MIXED UP SOAP NOTE – Nurs 5220 Advanced Health Assessment | |||
| Breasts : no lumps or masses | |||
| Respiratory : negative for cough; dyspnea on exertion; denies chest pain | |||
| CV/peripheral vascular : Denies issues with her heart, no palpitations | |||
| GI : Normal bowel sounds, soft, non tender, non distended. No guarding or rebound; no abdominal pain or problems with voiding or stooling, denies constipation or diarrhea and no blood in her stool | |||
GU: Negative for pai
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