solved. Question
Answered step-by-step
Asked by kkrb23
SOAP note along with ROS and Physical exam for a patient that presents with the following:Â
25-year-old African American female with a 3-day history of rhinorrhea, cough and fever, sudden onsetÂ
with clear rhinorrhea, nasal congestion, and sore throat. Nonproductive cough coming from down inÂ
chest, not throat. Symptoms quickly progressed to include generalized body aches, headache behindÂ
bilateral eyes (rates 5 on pain scale), T. max 103. Treating fever and body aches with OTC Ibuprofen (1-2Â
tabs twice a day as needed) with some relief, Nyquil with no improvement. Cough is intermittent, occursÂ
every few minutes. No change in time of day or positioning. Interfering with activity, sleep, and workÂ
attendance. Exposed to ill contacts at her workplace with similar symptoms. Has not seen a provider forÂ
current illness.
NKDA, no food allergies Meds: OTC Nyquil Q HS prn and OTC ibuprofen 1-2 tablets bid prn X 2 daysÂ
Hydrochlorothiazide (HCTZ) 25 mg QD No herbals/supplements, pain medication Chronic Illness:Â
Hypertension x 2 years, last follow-up visit 6 months ago Surgeries/Hospitalizations: Tonsillectomy as aÂ
child OB;GYN: G1, P1, A0 IUD x 1 year, no menstrual cycles since IUD placement Mental HealthÂ
Diagnoses/Hospitalizations: None
Child, no chronic health problems Mother: living age 55, HTN x 20 years Father: living age 56, Type IIÂ
Diabetes and Hyperlipidemia x 10 years Brother: living age 30, HTN x 3 years MGM: living age 75, HTN,Â
hyperlipidemia MGF: deceased due to a work accident PGM: living age 76, Osteoporosis, COPD PGF:Â
living age 77, HTN, Type II Diabetes, CVA
Employed fulltime at local telemarketing company Completed high school Married, monogamous, livesÂ
with husband and 1 child age 5 Smoker 1 ppd x 7 years, does not smoke in the home or vehicle HusbandÂ
nonsmoker Denies illicit drug use and ETOH Diet: Cooks often, foods high in fat (a lot of fried foods/redÂ
meat, few vegetables/fresh fruits Exercise: No formal exercise Stress/social support/hobbies: reportsÂ
low perceived stress
Vital Signs: Temp. 102, B/P 140/90, P 85, RR 20, BMI: 32, Oxygen sats 97% RA
SCIENCE
HEALTH SCIENCE
NURSING
MSN 621
