Nr 509 Week 5 Soap Note Advanced Physical Assessment

SOAP Note TemplateInitials : E.P. Age: 78 years old Gender: FemaleHeight Weight BP HR RR Temp SPO2 Pain Allergies 62 inches 54.43 kg 110/70 92 16 37.0 C 99% Medication: No known drug allergiesFood: No known food allergiesEnvironment: Reports latex allergy-contact dermatitis History of Present Illness (HPI)Chief Complaint (CC) Pain in my belly and Im having difficulty going to the bathroom 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 Patient reports abdominal discomfort that started 5 days agoL ocation Lower abdomen, PT states low in my bellyD uration Constant discomfort for 5 days and has gradually worsened over the last 2-3 daysC haracteristics Constant dull, crampy abdominal pain that stays in one place. At onset of pain patient reported 3 out of 10. Patient currently rates pain 6 out of 10. Experiencing bloating and increased flatulence. A ggravating Factors Moving around the house, gardening, eatingR elieving Factors Resting, and trying