MIXED UP SOAP NOTE – Nurs 5220 Advanced Health Assessment

SOAP Note Form
S/ Identifying Information: A.J, 15, F MIXED UP SOAP NOTE – Nurs 5220 Advanced Health Assessment		Family Hx: Parents: Dad has a high-stress job and hyper tension, on medications, Mom is a stay at home mom, +weight issues but overall no meds and healthy. Siblings (one in college, girl, +weight issues and overall healthy), brother (senior in high school, is looking at going away to school, healthy). Mom states no mental health concerns in the family, denies diabetes, exposure to communicable diseases, no recent travel outside of the US, no smokers, no stroke, lung disease, or asthma, no blood disorders, seizures, headache. Paternal grandfather with hypertension

		Personal/Social Hx: Has few school friends. Denies drugs, alcohol or use of illegal substance, no sports enhancing drugs; denies sexual encounters, she likes boys, denies a boyfriend
Chief Complaint/RFE: Left leg pain

Hx Present Illness: (7 Variables but do not list as such)she had left leg injury 3 days ago; previous left knee injury;

CURRENT HEALTH
Medications: Motrin 600 mg 3-4 times a day
Allergies: NKA
Last PE & Screenings: Previous left knee injury one year ago, no other broken bones to injuries
Immunization Status: yearly flu shots, and last got immunizations around age 11 and had one HPV and one Hepatitis A immunization at age 11
LMP & Birth Control (if applicable): N/a
PMH
Illnesses & Trauma: none
Hospitalizations/Surgeries: never been hospitalized;
OB Hx/Sexual Hx: regular period; began at 12 years
Emotional/Psy Hx: concerns with height; often notes that she is taller than other gymnasts and gets frustrated that she is not as limber or agile as her other competitors.no major mental health concerns; short tempered and sad due to the injury
REVIEW OF SYSTEMS
General : Negative for fevers, chills, fatigue; weight loss
Nutrition : eats a healthy diet; wants to become vegetarian; not obese
Skin/Hair/Nails : negative for itching, burning, rashes; red and sore at the site of injury
HEENT: denies vision or hearing problems; does not wear glasses or hearing aids; denies nasal drainage, nose bleeds and problems with smell and taste; No sore throat or voice changes, no mouth or teeth issues, and routinely sees a dentist, last visit in the past six months. MIXED UP SOAP NOTE – Nurs 5220 Advanced Health Assessment
Breasts : no lumps or masses
Respiratory : negative for cough; dyspnea on exertion; denies chest pain
CV/peripheral vascular : Denies issues with her heart, no palpitations
GI : Normal bowel sounds, soft, non tender, non distended. No guarding or rebound; no abdominal pain or problems with voiding or stooling, denies constipation or diarrhea and no blood in her stool
GU: Negative for pain; urine normal in frequency and quality
MSK : positive for painful on the left leg
Psych : negative for mental issues or trauma
Neuro : denies syncope
Lymph/Heme/Endocrine : negative for enlarged nodes in the groin. No history of splenectomy
O/ Physical Exam: T: 37.0C HR: 88 RR: 16 BP: 110/72 HT: 5.6” WT: 70.5Kg BMI: 24.2
General : appears sad and in pain
Skin : no rashes and lesions
Head : no head injuries; headache
EENT no eye or vision issues, hearing or ear pain; nasal drainage, nose bleeds, or problems with smell or taste. No sore throat or voice changes, no mouth or teeth issues, and routinely sees a dentist, last visit in the past six months.
Neck: no lumps; pain ; no sore throat
Breasts/Chest : no palpitations or chest pain
Lungs : clear to auscultation and percussion bilaterally
Heart/ perip vascular : . pulses+2 bilat pedal and +2 radia
Abdomen : symmetrical without distention; bowel sounds are normal in quality and intensity; No masses or splenomegaly noted; negative for tenderness with deep palpation
Genitalia/Rectum : no itching or reddening MIXED UP SOAP NOTE – Nurs 5220 Advanced Health Assessment
Lymph : no inflamed lymph nodes
MSK : left leg pain
Neuro : no problems with concentration at school or any memory issues.
Medical Dx: (2max) : X-ray Physical examination Symptom history	Rule Outs (only if applicable):
	Health Profile:
	age/gender/racial risks:
Pertinent Positives:(1DX) muscle injury; pain
	personal/family:
	screening needs:
Pertinent Negatives: Broken bone	counseling needs:
	Immunization/chemo needs:
Differential DX:(3-5) · Muscle or tendon injury · Medial tibial stress syndrome · Stress fracture, · Exertional compartment syndrome · Nerve entrapment,	Alteration in Health Prevention R/T:
	Screening deficits:
	Counseling deficits:
Nursing Dx: • Muscle or tendon injury	Immunization/chemo deficits:

I. PLAN: Do separate sections in the plan to include: Max 1-2 pages

Diagnostics:

· Grade 2 Muscle or tendon injury

Medications/Treatments:

· Over-the-counter (OTC) nonsteroidal anti-inflammatory drugs (NSAIDs), such as ibuprofen and naproxen; for pain relieving

Education:

· Recovery exercise; massage Therapy; appropriate muscle resting

Follow-up:

· Visit clinic every two weeks

Referrals:

· Physical therapist

Prevention Plan:

· Patient will walk at a moderate pace for 3 to 5 minutes before doing any sports or other physical activities.

· Wear shoes that provide stability and ensure that any other protective equipment fits appropriately and is in good condition. MIXED UP SOAP NOTE – Nurs 5220 Advanced Health Assessment.

· Lift heavy objects or items with care and always use the correct technique.

II. Rationale: ( Max 2 pages)

Muscle strain occurs from overstretched muscles and is common among sporting people. Symptoms include leg pain and mobility difficulties among others.

III. Patho: (Max 2 pages)

Muscle strains cause excessive fiber stretching due to exertion of tensile force at the muscle. The pathophysiological process is characterized by destruction, repair and remodeling. Destruction involves tearing and myofibrils necrosis, creation of hematoma and division of inflammatory cells. Repair and remodeling phases involve necrotic tissue phagocytosis, myofibrils regeneration and concomitant development of connective scar tissue, neoformation of vessels and growth of neurons also occur MIXED UP SOAP NOTE – Nurs 5220 Advanced Health Assessment