SOAP Note: Tina Jones
SOAP Note: Tina Jones
Greeting
Tina Jones is a 28 year old African American female. She is single and lives with her mother.
... [Show More] Tina is the primary source of her health is tree and has offered the information of her own free will. Tina speaks english and her speech is clear and coherent. During the interview Tina has maintained good eye contact.
General Survey
This is Tina Jones. She is a 28 year old, african american female. Tina appears to be well groomed and well dressed. Tina is alert and oriented to her surroundings. Tina weighs 90 kg and is 170 cm, with a BMI of 31. Tina's facial features are symmetrical with movement and there are no overall signs of acute distress. Based on appearance and body mass index Tina appears to be overweight. Tina's body parts appear to be equal bilaterally and are relevant in proportion to her body. Tina appears to have good posture and a sitting comfortably on the table. Rang of motion and gate seems normal. Tina has appropriate facial expressions mood and affect speech speech patterns and dress all seemed normal and appropriate for her age.
S:
• CC: “ Patient is in the office today for "scrape on my foot...it's looking pretty nasty. and the pain is killing me!"
o EMPATHY!!!!!!
• HPI:
o Onset: One week ago.
o Location: plantar surface of right foot
o Duration:
o Characteristics/description: Reported that she tripped on the stairs while walking scrapping the ball of her foot. She has noted that
o Aggravating factors: Walking and standing the wound has started oozing but denies odor.
o Relieving factors: Tina stated that the “pain pills” relieve the pain for a short time.
o Treatment: Tina sought treatment at the emergency deparment. Tine received a prescription for the pain medication Tamadol. Tina has been cleaning the laceration twice a day with soap and water as well as peroxide if it was “irritated”. She has used Neosporin and bandaged the area.
o Current pain/pain at its worst (pain scale) Her current pain level is 7/10. Tina has reported that her pain was a 9/10 when she bears weight on the foot.
o EDUCATION!!!!
• Current Meds:
o What? Why?Dose,Frequency, Started when?Last time taken, Help the diagnosis?
o Allbuterol inhaler 90mcg/spray last used three days ago. Tina stated that she uses her inhaler PRN and has needed to use it two to three thimes a week recently.Tina is taking Tramadol 50 mg three times a day, last taken this morning around 830. Tina stated that this helps control the pain for a few hours. Tina takes Acetaminophen 500-1000 mg PO prn for hear headaches.Tina denies taking any supplements, herbs or viatamins on a daily bases. Tina uses Neosporine on her right foot. Tina take Advil 200mg PRN for menstral cramps.Any vitamins? Denies
o Supplements? Denies
o Herbs? Denies
o EDUCATION!!!!! And “Thank you for telling me about your meds…”
• Allergies:
o Meds: PCN reaction rash and hives.
o Environmental: Tina is allergic to cats. She gets itchy eyes, sneezing and stated that her “asthma acts up” around them
o Latex: Tina denies a latex allergy.
o What happens?
o When discovered?
o How treated?
• PMH:
o When dx’d? Asthma at 2 1/2 years old, Diabetes at 24 years old
o How managed?
o Last “flare-up/episode”
o Describe symptoms
o Hospitalizations: Went to the ER one week ago for her injury to her right foot. Prior to that she has only been to the hospital for asthma attacks. The first Asthma attack was when she was 16 years old. Tina stated that she has been to the hospital “maybe five times total” for her asthma.
o Triggers/aggravating factors
o Sx
o EDUCATION/EMPATHY!!!! ESPECIALLY WITH T2DM/BLOOD SUGAR CHECKS, ETC. And “Thank you for telling me about your history…”
• Social Hx:
o Education level: Tina is in school for her Bachelor’s degree in Accounting.
o Living situation: Tina has recently moved back in with her mother following the death of Tina’s father.
o Stressors/current stress level: Tina stated “I feel pretty worried about my foot”, this is causing some stress in her life due missing school and work due to
o Religious affiliation: Tina is very active in her church.
o Activity level:
▪ Regular exercise
o Occupation: Tina has works since highschool as a supervisor at Mid-American Copy and ship. She stated she works 32 hours a week and is sometimes flexed
▪ Hrs worked
o Diet/nutrition:
▪ Last meal
• What?
• When?
▪ Usual daily food
▪ Salt intake
▪ Caffeine intake
▪ Recent diet changes
▪ Appetite
▪ Sodas
o Substance use:
▪ EDUCATION!!!!!!
▪ Illicit drugs: Denies
• What: Smoked pot
• First tried when? 15 years old
• How often used? Every weekend but hasent done it in “a long time”
• Last used? At age 20 or 21
▪ Alcohol
• How much? She is social drinker of alcohol. She stated no more than two to three in a sitting.
• First tried when? In high school around age 15 or 16
• Last drank? At least 3 weeks ago
▪ Cigarettes/tobacco: Denies
• Ever?
• When?
• How much?
• Last one?
• Desire to quit?
o Health maintenance:
▪ EDUCATION!!!!
▪ Immunizations
• Tetanus: Received a tetanus booster about a year ago.
• Childhood imm: Received a hepatitis vaccination but is unsure it is was hepatitis A or B that she received. Received the meningitis vaccine at 19 years of age. All childhood immunizations she stated she was “pretty sure:” she got. Stated she had the chicken pox and therefore did not need to get vaccinated.
• Flu vax
▪ Sunscreen/exposure: Tina denies uses sunscreen when outdoors but stated she would use “if I went swimming”.
▪ Seatbelt
• Family Hx:
▪ Fire extinguisher
▪ Helmet
▪ Guns
• RepDo you have a family history of colon cancer?
• Do you have a family history of GERD?
• Do you have a family history of irritable bowel syndrome?
• Do you have a family history of cholecystitis?
• Do you have a family history of liver disease?
• Do you have a family history of kidney disease
•
o Mom: Still alive and is 50 years old, Hypothyroid, High Cholesterol and hypertension
o Dad: Died in a car accident at 58 years old. Has history of Type 2 diabetes, high cholesterol and hypertension.
o PGF: Died in his mid 60’s from colon cancer. Has history of Type 2 diabetes and high blood pressure.
o PGM: Still alive history of hypertension.
o MGF: Died of a heart attack. Hypertension and cholesterol.
o MGM: Died at age 73 from a stroke. High cholesterol and hypertension.
o Siblings: Brother who is overweight and Younger sister who has asthma.
o Uncle with a history of Alcoholism.
o EDUCATION/EMPATHY!!!!! “I’m so sorry your dad died…. Thank you for telling me about your family history…”
• ROS:
o Constitutional:
▪ General well-being: Concern for pain in her foot.
▪ Recent illness
▪ Sleep patterns: Recent change in sleeping patterns after the death of her father. Tina stated that she tries to get 8 hour but has only be achieving between 6 or 7 hours a night.
▪ Fever: Recent fever last night.
▪ Chills: Stated chills last night before her fever stated.
▪ Wt loss/gain: Stated that she has recently lost ten pound in the last month, but has not changed her diet.
▪ Dizziness/lightheadedness: Denies
▪ Palpitations: Denies
▪ Night sweats: Denies being sweaty, however, stated that she gets hot at night and needs to remove her bed sheets.
▪ Weakness/fatigue: Denies weakness. Has been feeling exhausted
especially towards the end of the day.
▪ EMPATHY/EDUCATION WHERE POSSIBLE!!!!
o HEENT:
▪ Vision changes: Tina stated that her vision has worsened over the past few years.
• Blurred vision: when reading
• Double vision: none
• Last vision exam: Had eye exams as a kid but has not had one since then.
o EDUCATION WHERE POSSIBLE!!!!
• Eye drainage/itchiness/pain: headache when reading for too long.
▪ Hearing loss
• Ear pain: Denies
• Ear drainage: Denies
▪ Sneezing: around cats and dust
▪ Congestion:
▪ Runny nose
▪ Sore throat: none
▪ Taste change none
▪ Difficulty swallowing none
▪ Mouth problems none
▪ Tongue problems none
▪ Teeth problems none
▪ Last dental exam: a few years ago.
• EDUCATION IF APPLICABLE!!!
o Skin:
▪ H/o skin dz
• Treatment
▪ Fam h/o allergies/allergic skin dz
▪ Allergies to drugs/plants/animals
▪ Birthmarks : denies
▪ Tattoos : denies
▪ Sores that don’t heal; the sore on her foot
▪ Excessive dryness/moisture: Arms and legs get dry.
▪ Rash/lesions: : denies
▪ Itching: denies
▪ Changes
▪ Moles: Has some moles, but has not noticed any changes in them recently.
▪ Color/pigmentation changes: She has noticed some discoloration on her
neck and stated “it is looking weird”.
▪ Acne: She has had acne that is treated by washing her face every night.
▪ Temp changes: She stated feeling warm last night.
▪ Hair loss : denies. States that she has facial hair and belly hair.
▪ Nail changes: denies
▪ Occupational/environmental changes affecting skin
▪ Insect bites
▪ Skin self-exam? Denies
• EDUCATION!!!
o Cardio: : denies
▪ EDUCATION/EMPATHY WHERE APPLICABLE!!!
▪ PMH
• Angina
• Circulation problems
• Clots
• Rheumatic fever
• Heart murmur
• Cyanosis
▪ Family Hx
• MI
• Stroke
• PE
▪ CP or tightness? Only when she is having breathing problems.
• Onset
• Location
• Character/description
• Brought on by activity
• Associated symptoms
• Made worse by movement
• Relieved by rest or NTG
• Current pain level
▪ Dyspnea
• What brings it on
• Onset
• Duration
• Affected by position
• Awaken you from sleep
• Interfere with activities
▪ Orthopnea
• How many pillows
▪ Cough
• Duration
• Frequency
• Type
• Mucus? Color? Odor? Blood?
• Associated with activity/position
• Activity make it better/worse
• Relieved by rest/meds
▪ Fatigue
• Tire easily?
• Able to keep up with coworkers
• Onset
• Related to time of day
▪ Cyanosis or pallor
▪ Palpitations
▪ Edema
• Onset
• Recent change
• What time of day
• How much swelling
• Legs swollen equally
• Go away with rest/elevation/after night’s sleep
• Associated symptoms
▪ Nocturia
• How long
• How often
• Recent change
o Resp:
▪ SOB due to asthma symptoms.
▪ Cough : denies
▪ (MUCH OF CV COVERS RESP TOO)
o GI:
▪ EDUCATION/EMPATHY WHERE APPLICABLE!!!
▪ Appetite/wt change: Stated that she has had increased appetite.
▪ Dysphagia
▪ Food intolerance: denies
▪ N/V/D/C : denies
• How often?
• Blood
• Food in the last 24h/where eaten
• Recent travel
o Drink local water/food
o Swim locally
• BMs
o How often: every day or every other day
o Color
o Consistency: patient stated that they are not hard or soft
o Changes recently
o Laxatives
▪ Abd pain: denies
• Where
• When
• Constant or intermittent
• Quality
• Relieved w/eating or worse
• A/W period, stress, fatigue, gas, fever, rectal bleeding, vaginal/penile discharge
• Attempts at relief
▪ Hx
• GI issues
o GB
o Ulcer
o Hepatitis/jaundice
o Appy
o Colitis
o Hernia
o Sx
o XR
▪ Bloody stools
▪ Gas
▪ Bloating
▪ GERD : denies
o GU:
▪ Burning w/urination : denies
▪ Urinary hesitancy: denies
▪ Hematuria : denies
▪ Increased frequency: has had increase frequency of urination.
▪ GYN/sexual hx:
• LMP: Approximately 3 weeks ago
• Describe periods
o Frequency
o Length
o Severity
o Neuro:
• BC: Stopped taking birth control “a couple of years” ago.
o EDUCATION!!!!
• Menarche: age 11 for first period.
• First sexual experience: 18 years Old
• Protected? Uses condoms occasionally.
o EDUCATION!!!!
• Last time had sex: 2 years
• STI symptoms?
• Tested for STIs? Thinks she was tested during her last pap smear.
• Partners with STIs? None
• . Number of partners: 3 male partners
• Last Pap: 4 years ago
o EDUCATION!!!
• Abnormal pap? None that she knows of.
• Ever pregnant/kids? No pregnancies
• Pregnant now? Not currently pregnant.
▪ HA/injury
▪ Dizziness/vertigo
▪ Sz’s
▪ Numbness/tingling
▪ Syncope
▪ Bladder/bowel control changes : denies
o Musculoskeletal:
▪ Joint problems/pain? : denies
• Where?
• Onset
• Quality
• Severity
• When?
• How long does it last?
• How often does it occur?
• Chills/fever/sore throat/trauma/repetitive activity?
• Stiffness?
• Swelling/heat/redness?
• Tick bite?
• Limited ROM?
o What activities aggravate?
▪ Injuries: : denies
• Knee
o How did you injure?
o Pop?
o Bear weight?
o Flex?
▪ Muscles: : denies
• Pain/cramping
• Aggravating/alleviating factors
• a/w fever/chills/flu?
• Weakness
▪ Bones: : denies
• Bone pain
• Deformity
• Accidents/trauma
o When?
o Tx?
• Back pain
o Where?
o Radiating?
o Numbness/tingling
▪ ADLs
• Limits to ADLs
o Bathing
o Toileting
o Dressing
o Grooming
o Activities of Daily LivingEating
o Mobility
o Communicating
▪ Pt-centered care
• EDUCATION!!!
• Occupational hazards?
• Heavy lifting?
• Repetitive motion/chronic stress to joints?
• Efforts to alleviate?
• Exercise? Has lack of energy for exercise.
o Type
o Frequency
o Warm-up
o Pain during exercise
• Wt gain
o Hematologic:
▪ Anemia
▪ Bleeding
▪ Bruising : denies
▪ Fam h/o sickle cell
o Lymphatics:
▪ Leg pain/cramps
• Describe
• Aggravated by activity
• How much aggravates pain
• Pain changed recently
• Worse with elevation
• Worse with cool temps
• Pain wake you up at night
• Recent changes in exercise
• What relieves
• Associated with sexual function change
▪ Changes to arms/legs
• Color
• Temp
• Veins look bulging/crooked
• Support hose
• Leg ulcers/sores
• Swelling
o What time of day
o Intermittent or constant
o What brings it on
o What relieves
o Associated with pain/heat/redness/ulceration/hardened skin
▪ Enlarged nodes
• Where
• Recent change
• Hard, soft
• Associated with pain/local infection
▪ Splenectomy
o Psych:
▪ Depression: Dealt with some depression after the death of her father, but no long term depression noted.
▪ Anxiety: has had some anxiety this year dealing with the death of her
father.
▪ EMPATHY WHERE APPLICABLE!!!
o Endo:
▪ Excessive sweating : denies
▪ Cold/heat intolerance: Stated that she “gets warm sometimes”
▪ Polyuria/polydipsia: Recently been dealing with polydipsia and polyuria
o Allergies:
▪ Eczema : denies
O:
• Physical Exam:
• Diagnostic results: anything done in visit now or in past visit for today
A:
• Differential Diagnoses (3): with ICD-10 and supporting s/s from pt
P:
• Diagnostics: what are we doing today? What are we sending pt for?
• Rx:
• Education:
• Referral/consults:
• Follow up: when do we want pt back? Backup plan? ER?
Reflection Explicitly describe the tasks you undertook to complete this exam.
Explain the clinical reasoning behind your decisions and tasks.
Identify how your performance could be improved and how you can apply “lessons learned” within the assignment to your professional practice. [Show Less]