Nr 509 Soap Note Week 6 Advanced Physical Assessment

SOAP Note Template Week 6Initials: D. R. Age: 8 Gender: MaleHeight Weight BP HR RR Temp SPO2 Pain Rating Allergies (and reaction)127 cm 40.9 kg 120/76 100 28 37.2 C 96% Medication: KNAFood: KNFAEnvironment: KNEA History of Present Illness (HPI)Chief Complaint (CC) I have been coughing, feel tired, with increased runny nose, sore throat and right ear pain. CC is a BRIEF statement identifying why the patient is here - in the patients own words - for instance "headache", NOT "bad headache for 3days. Sometimes a patient has more than one complaint. For example: If the patient presents with cough and sore throat, identify which is the CC and which may be an associated symptomO nset 5 DaysL ocation Sore throat, productive cough, increased runny nose, with right ear painD uration Runny nose constant but increased since cough began 5 days ago, sore throatfor 5 days, and right ear pain since yesterday. C haracteristics Productive cough and runny nose produce clear mucus, increased tiredness during activity, sore throat when swallowing, right ear pain A ggravating Factors Nighttime, recess R elieving Factors Cough medicineT reatment Cough medicineCurrent Medications: Include dosage, frequency, length of time used and reason for use; also include