Characteristics Of Soap Analysis Notes

1807 WordsOct 30, 20178 Pages
Week 2 SOAP notes Note: For the sake of clarity I left sample SOAP note information in italics. My write-up contribution is in regular font. Data that requires specialized equipment is in parentheses. Patient Information: KD, 17, Female, Caucasian, Blue Cross S. CC: Sinus congestion, rash, and abdominal pain HPI: Onset: sinus congestion began 6 days ago, abdominal pain began 2 days ago, and rash began yesterday Location: frontal and maxillary sinuses, rash on torso, abdominal pain in lower 2 quadrants Duration: all symptoms constant Characteristics: Sinus congestion w/ aching pressure-type headache; Rash is hot w/ some itching; abdominal pain is cramping w/ intermittent nausea Aggravating Factors: sinuses worse in the AM; rash worse w/…show more content…
CARDIOVASCULAR: No chest pain, chest pressure or chest discomfort. No palpitations or edema. RESPIRATORY: No shortness of breath, cough or sputum. GASTROINTESTINAL: lower abdominal pain and cramping with intermittent nausea. Increased frequency of BM, 3-4x/day. No anorexia, vomiting or diarrhea. No blood. GENITOURINARY: No burning on urination. Last menstrual period, 08/15/2017. NEUROLOGICAL: No dizziness, syncope, paralysis, ataxia, numbness or tingling in the extremities. No change in bowel or bladder control. MUSCULOSKELETAL: No muscle, back pain, joint pain or stiffness. HEMATOLOGIC: No anemia, bleeding or bruising. LYMPHATICS: No enlarged nodes. No history of splenectomy. PSYCHIATRIC: No history of depression or anxiety. ENDOCRINOLOGIC: No reports of sweating, cold or heat intolerance. No polyuria or polydipsia. ALLERGIES: Gets generalized headache when eats any amount of eggs. No history of asthma, hives, eczema or rhinitis. O. Physical exam: V/S: BP: 109/60; HR: 62; Resp:12; Temp: 99.5; Height: 5’ 9”; Weight: 164 lbs Constitutional: well-nourished teenage female w/ lean, muscular build; resonant quality of voice is dulled and suggests significant sinus congestion; good hygiene w/ clothing well kept; affect is positive and open, communicates with clinician easily Head: skull symmetrical w/ normal contour, no bumps, swelling or tenderness; TMJ normal ROM, no pain or clicking; temporal arteries

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