Nr 509 Week 6 Soap Note Advanced Physical Assessment

SOAP Note TemplateInitials : D.R. Age: 8 years old Gender: MaleHeight Weight BP HR RR Temp SPO2 Pain Allergies 127 cm 40.9 kg 120/76 100 28 37.2 C 96% Medication: No known drug allergiesFood: No known food allergiesEnvironment: No known environmental allergies History of Present Illness (HPI)Chief Complaint (CC) I have been coughing a lot 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 Started 5 days agoL ocation Throat and right earD uration Throat pain x5 days and ear pain x1 dayC haracteristics Productive cough every couple of minutes with clear sputum. Describes his cough as gurgly and watery Cough keeps the patient up at night. Cough is accompanied by a sore throat, right ear pain and worsening rhinorrhea with clear dischargeA ggravating Factors Worsens at 2100 every night. Exposed to second hand smoke by his father who smokes a cigar in the house multiple times a week. R elieving