Typhon SOAP note week 5

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School

Herzing University *

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Course

611

Subject

Health Science

Date

Feb 20, 2024

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docx

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5

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SOAP Note Week 5 NU611 Herzing University Name: Amanda Lee Typhon Encounter #: 4582-20231129-001 Comprehensive:____Focused:__X__ S: SUBJECTIVE DATA CC: “I am still nauseated and it hurts to eat” HPI: 17-year-old white female is presenting today with nausea and epigastric pain lasting 2 months. Pain is “nagging”, more frequently when the patient eats. Patient was seen in Sept at the onset of the symptoms and was given Nexium and referred to Cardiology. Patient states pain and nausea are unrelieved with meds, but admits to not taking them as directed. Patient was diagnosed with mitral valve prolapse, ordered heart monitor which was completed 1 month ago, and will f/u with cardio on Dec. 21. PMH: Mitral valve prolapse – October 2023 ALLERGIES No known allergies MEDICATIONS Nexium 20 mg daily SH Patient is a senior in high school and lives with both parents. She admits to smoking a vape once in which she became very ill and has not tried smoking again. Patient does not drink alcohol or use illicit drugs and is not currently sexually active. Patient states she drinks caffeine occasionally (maybe 3-4 caffeinated drinks per week). FH Father – irritable bowel syndrome Paternal grandfather – Crohn’s disease HEALTH PROMOTION & MAINTENANC E Patient is up to date with all childhood immunizations, does not have/nor wishes to get COVID or flu vaccine and has not received the Gardasil vaccine. She does not exercise regularly, but states she eats a good diet that includes fruits and veggies, does not eat anything spicy. ROS (put N/A in sections not completed day of exam) Constitutional Patient denies fever, chills, reports recent weight loss Head N/A Eyes N/A Ears, Nose, Mouth, Throat N/A Neck N/A Cardiovascular/Peripheral Vascular Denies chest pain, swelling/edema, or palpitations Respiratory Denies SOB, wheezing Breast N/A Gastrointestinal Reports some nausea, epigastric
SOAP Note Week 5 NU611 Herzing University Name: Amanda Lee Typhon Encounter #: 4582-20231129-001 Comprehensive:____Focused:__X__ pain, normal BMs. Denies blood in stool. Genitourinary Denies pain or complications with urinating Musculoskeletal N/A Integumentary N/A Neurological N/A Psychiatric (screening tools: Ex: PHQ-9, MMSE, GAD-7) N/A Endocrine N/A Hematologic/Lymphatic N/A Allergic/Immunologic N/A Other N/A O: OBJECTIVE DATA VITALS: HR: 92 RR: 17 BP: 118/62 Temp: 97.2 SpO2%: 100% Ht: 65” Wt: 129 BMI: 21.5 Age: 17 LMP: 11/25/23 PAIN: 0 PHYSICAL EXAM (Pertinent data related to presenting problem or visit type. Put N/A in sections not completed day of exam) General Appearance Patient is well-appearing, well- nourished, does not appear to be in any acute stress or discomfort Head N/A Eyes N/A ENT, Mouth N/A Neck N/A Cardiovascular/Peripheral Vascular S1, S2 audible, regular rate/rhythm, no murmurs, no edema present, cap refill <3 seconds. Respiratory Lung sounds clear throughout without wheezes Breast N/A Gastrointestinal Bowel sounds normoactive in all 4 quadrants Genitourinary Male
SOAP Note Week 5 NU611 Herzing University Name: Amanda Lee Typhon Encounter #: 4582-20231129-001 Comprehensive:____Focused:__X__ External Exam N/A Internal Exam N/A Genitourinary Female External Exam N/A Internal Exam N/A Musculoskeletal N/A Integumentary Skin warm and dry with no visible rashes or lesions Neurological N/A Psychiatric N/A Endocrine Thyroid palpable, symmetrical and non-tender Hematologic/Lymphatic N/A Allergic/Immunologic N/A Other N/A A: ASSESSMENT AND DIAGNOSIS DIAGNOSIS ICD-10 CODES PRIORITIZE DIAGNOSIS 1. EPIGASTRIC PAIN R10.13 VISIT CODES CPT BILLING CODES 99215 - OFFICE/OP VISIT, EST PT, MEDICALLY APPROPRIATE HX/EXAM; HIGH LEVEL MED DECISION; 40+ MIN DIAGNOSTICS POC TESTING N/A TESTS REVIEWED N/A
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