Nr 509 Soap Note Week 5 Advanced Physical Assessment

[Type here]SOAP Note Erin St Esprit Initials: E.P. Age: 7 8 Gender: Fem aleHeight Weight BP HR RR Temp SPO2 Pain Rating Allergies (and reaction)62 inches 120 pounds 110/70 92 16 37.0 C 98.6 F 99% Medication: NKA.Food: NKA.Environmental: Latex : itchy skin rash History of Present Illness (HPI)Chief Complaint (CC) I have pain in my belly. . . and I'm having some difficulty with going to the bathroom. My daughter was concerned. 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 days ago.L ocation Lower abdomen.D uration Constant. Worse when moving or when eating. (worse 2-3 days) .C haracteristics Constant. Dull and crampy. Generalized pain that stays in one place. (Last BM 5 days ago, non- radiating worsened over 2-3 days) Associated characteristics diarrhea, last BM .A ggravating Factors Moving or after eating. When I move around the house or try to garden, I feel more pain.R elieving Factors