NR 511 Wk2 SOAP Assignment

NR 511 Wk2 SOAP Assignment

Tommy

S: SUBJECTIVE DATA

Chief Complaint (CC):  “My ears hurt so badly they woke me up”

History of present illness (HPI):  Symptoms started yesterday with an itchy ear. The right ear is the problem. It hurts to touch and pain is 4/5 on Wong Baker visual pain scale. Pain increased when eating breakfast. Has taken Tylenol with no relief.

Past Medical History (PMH): Twin Full-term pregnancy, NSVD twin gestation 5 pounds 4 ounces.  No hospitalizations.  NKDA.  Daily medication – chewable children’s multivitamin with iron.

Family History (FH): Father and grandfather both smoke outside. Mother in good health. Grandparents are immigrants from Ireland. Grandmother has Hx of hypertension and hyperlipidemia. Grandfather has Hx of HTN and hyperlipidemia. Sister is recovering from a cold. Twin brother is recovering from a cold.

Social History(SH):  Lives with parents, grandparents and 3 siblings. In a K4 program and doing well. Grandparents care for him after school. Have 2 dogs and a cat.

Review of Systems (ROS).

General: (-) fever

Head: (-) headache

Eyes: (-) vision loss, (-)glasses, (-) acute vision loss, (-) discharge

Ears: (+) pain, (-)hearing loss, (-)ringing

Nose: (-)nasal congestion, (-) discharge

Mouth and throat, (-)sore throat, (-) difficulty swallowing

Cardiovascular: (-) chest pain, (-) palpitation, (-) dizziness

Respiratory: (-) Shortness of breath, (-)wheezes, (-) cough

Lymphatics: (-) swelling

0: OBJECTIVE DATA

Constitutional: alert, oriented and cooperative

VS:  height: 108 centimeters weight: 18 kilograms, B/P:100/60, T: 98.7 HR: 94 BPM/reg., R: 18, regular, non-labored, SpO2: 99% BMI: 16.6

HEENT: head normocephalic. Hair thick with distribution throughout scalp.

Eyes: Conjunctiva clear, non-icteric, PERRLA, EOM’s intact.

Left ear:

Cardiopulmonary: Heart S1 and s2 noted, no murmurs, noted. Lungs clear to auscultation bilaterally. Respirations unlabored.  Abdomen sl. rounded with active bowel sounds, soft, non-tender, no masses or organomegaly.

Testing Results: none

A: ASSESSMENT:

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NR 511 Wk2 SOAP Assignment

Paddy

S: SUBJECTIVE DATA

Chief Complaint (CC):  “Ear have been popping, feel stuffy, and my ear hurts”

History of present illness (HPI):  Symptoms started yesterday. The left ear is the problem. Pain is constant 3/5 on Wong Baker visual pain scale. It feels like someone is stabbing me in the ear. Tylenol has helped on a little.

Past Medical History (PMH):  Twin Full-term pregnancy, NSVD twin gestation 5 pounds 2 ounces.  No hospitalizations.  NKDA.  Daily medication – chewable children’s multivitamin with iron.

Family History (FH): Father and grandfather both smoke outside. Mother in good health. Grandparents are immigrants from Ireland. Grandmother has Hx of hypertension and hyperlipidemia. Grandfather has Hx of HTN and hyperlipidemia. Sister is recovering from a cold. Older brother is in good health.

Social History(SH):  Lives with parents, grandparents and 3 siblings. In a K4 program and doing well. Grandparents care for him after school. Have 2 dogs and a cat.

Review of Systems (ROS).

General: (-) fever

Head: (-) headache

Eyes: (-) vision loss, (-)glasses, (-) acute vision loss, (+) discharge

Ears: (+) pain, (-)hearing loss, (-)ringing

Nose: (-)nasal congestion, (-) discharge

Mouth and throat, (-)sore throat, (-) difficulty swallowing

Cardiovascular: (-) chest pain, (-) palpitation, (-) dizziness

Respiratory: (-) Shortness of breath, (-)wheezes, (-) cough

Lymphatics: (-) swelling

0: OBJECTIVE DATA

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