MN552 Advanced Health Assessment – SOAP Note Section II & III: History of Lifestyle Patterns and Review of Systems ROS
SOAP Note Section II: Lifestyle Pattern and Section III: ROS
This section of the SOAP note will include history of lifestyle patterns and the review of systems (ROS).
- Document appropriate data in the relevant body system.
- Do not state “Negative, NA or Unremarkable” for any systems because the reader will not know which questions were actually asked by the provider.
- This is a comprehensive health history and should not contain physical exam findings. The focused history data is relevant to the chief complaint and identified by pertinent positive data documented during the health history.
- Address each component of the SOAP note as noted in the written guide with relevant data.
- You may continue with the same volunteer to complete each section of the SOAP note.
- Click here for the written guide for this Assignment.
- MN552 Advanced Health Assessment – SOAP Note Section II & III: History of Lifestyle Patterns and Review of Systems ROS
MN552 Advanced Health Assessment – SOAP Note Section II & III: History of Lifestyle Patterns and Review of Systems ROS
MN552 Advanced Health Assessment
Unit 2 SOAP Note Section I Written Guide
History, Interview, and Genogram Guide
Date of History/Interview:
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Source of history and Reliability: (client)
- Biographical Data
- Name (use initials only): W.W.
- Address: George street, House no. 4, California
- Phone number 305-555-5555
- Primary language: speaks English
- Authorized representative: her daughter
- Age and Date of Birth: 50 y/o, July 15, 1967
- Place of Birth: San Diego, California
- Gender: female
- Race: black
- Marital Status: divorced
- Ethnic/Cultural Origin: African
- Education: master’s in criminology
- Occupation/Professional: lecturer
- Health insurance: full medical coverage
- Chief Complaint (reason for seeking health care):
- Brief spontaneous statement in client’s own words
“The cough started as a chest cough but it has not been better since my first time visit to the clinic. During the day it doesn’t bother me as much, but during the night I cough a lot. For the last few weeks I have experienced pain in the chest.”
- Includes when the problem started
“I started coughing like three months ago. I have undergone treatment from regular hospitals but nothing seems to change.”
- History of Present Illness: A well organized, chronological record of client’s reason for seeking care, from time of onset to present. Please include the 8 critical characteristics using the PQRSTU pneumonic.
P – Provocative or palliative
The client states that in most cases room temperature affects her cough, when she feels cold she coughs more. She is also affected by strong smells like perfumes, and states that she cannot sit directly under a fan or air conditioner because the strong wind promotes her cough. MN552 Advanced Health Assessment – SOAP Note Section II & III: History of Lifestyle Patterns and Review of Systems ROS.
Q – Quality or quantity
The client feels pain in her chest when she coughs. Her throat is also sore. The cough produces sputum that seems clear.
R – Region or radiation
She only has coughing problem. No other complains.
S – Severity
The severity according to the patient is at 6 out of 10.
T – Timing
She states that when she starts coughing it can last for more than five minutes without stopping. She coughs mostly during the night or when she is irritated by a disturbing smell during the day or even strong wind.
U – Understand Patient’s Perception of the problem
Her fever seems low grade at 100 degrees without chills. After a long conversation with the client she says that she is worried she might have pneumonia. She has not had shortness of breath, she also denies postnasal drip. She has undergone chest X-rays, TB test, and taken many over the counter drugs and home remedies, with no improvement. MN552 Advanced Health Assessment – SOAP Note Section II & III: History of Lifestyle Patterns and Review of Systems ROS.
- Past Medical History
- Medical Hx: major illnesses during life span, injuries, hospitalizations, transfusions, and disabilities.
No other major medical complications, she was diagnosed with diabetes at age 45, present concern is only her cough. hospitalized once for vaginal delivery, no other surgical hx.
- Childhood Illnesses: Measles, chickenpox, Mumps, strep throat
- Surgical Hx; dates, outpatient, X-rays.
Vaginal delivery on 02/26/1987, Chest X ray 08/15/2017
- Obstetric HX:
Only one pregnancy, and one delivery, she gave birth to her daughter who is the only child.no miscarriages or abortion cases.
- Immunizations: only as a child, immunization like MMR, Varicella, Tetanus, has not received busters as adult, but last visit to the doctor they gave her the flu shot. Patient states that she does not like getting vaccines.
- Psychiatric Hx: no psychiatric conditions reported.
- Allergies: allergic to dust
- Current Medications: Metformin 500mg BID for diabetes type 2.
- MN552 Advanced Health Assessment – SOAP Note Section II & III: History of Lifestyle Patterns and Review of Systems ROS
No eye problem
No foot problem
There are some cavities
No hearing problem
EKG; normal
Chest X-Ray; diffuse wheezes are present bilaterally with expiration. No crackles or bronchi.
Pap test; no cervical cancer
Mammogram; no signs of breast cancer
Serum cholesterol; cholesterol level is at 200
Stool occult blood; no colon cancer
Prostate; not relevant
PSA; not relevant
UA; not collected
TB skin test; not detected
Sickle- cell; no sickle cell disease
PKU; non-applicable
Hamatocrit; 35% – normal
Genogram Three Generation
Section 2
This section has a family medical history as stated by the patient. Patient states that she is currently divorced from her husband whose whereabouts are unknown, prior to divorce he was in good health. Patient W.W. had one daughter with her ex-husband, she is alive and has history of asthma. Patient narrates that her mother is alive and heathy for her age, her father is deceased, he had a history of heart failure. Her maternal grandmother is alive and overall healthy, just debilitated due to her age, her maternal grandfather had a heart attack and is deceased. Patients grandmother is alive with arthritis, and her paternal grandfather is alive with diabetes. On the Ex-husband family side, she knows in his family in his mother’s side his mother is alive and with diabetes, his father alive and with hypertension, his grandmother had a stroke and is deceased, and his grandfather had committed suicide. On her Ex-husbands fathers side his grandmother alive with diabetes and HTN and his grandfather is alive with prostate issues and diagnosed with BPH. MN552 Advanced Health Assessment – SOAP Note Section II & III: History of Lifestyle Patterns and Review of Systems ROS.
MN552 Advanced Health Assessment – SOAP Note Section II & III: History of Lifestyle Patterns and Review of Systems ROS
MN552 Advanced Health Assessment
Unit 3 SOAP Note Section II and III Written Guide
- Document appropriate data in the relevant body system.
- Do not state “Negative, NA or Unremarkable” for any systems because the reader will not know which questions were actually asked by the provider.
- This is a comprehensive health history and should not contain physical exam findings. The focused history data is relevant to the chief complaint and identified by pertinent positive data documented during the health history.
- Address each component of the SOAP note as noted in the written guide with relevant data.
- You may continue with the same volunteer to complete each section of the SOAP note.
- MN552 Advanced Health Assessment – SOAP Note Section II & III: History of Lifestyle Patterns and Review of Systems ROS
- Life style patterns
- Immigrant status
- Spiritual resources/religion
- Health perception
- Nutritional patterns: Appetite (any changes); satisfaction with current weight; gains or losses; recall of usual intake; any cultural restrictions/intolerances; amount of fluid per day and type
- Elimination patterns: Bowel (usual pattern and characteristics); bladder (usual pattern and characteristics); any incontinence
- Living environment: City, state; urban, rural, community; type of dwelling, facilities; known exposures to environmental toxins
- Occupational health: Known exposure to environmental toxins at work
- Functional assessment: ADLs, IADLs, interpersonal relationships/resources (see page 57 in Jarvis textbook)
- Role and family relationships: Immediate family composition; how are family decisions made; impact of family member’s health on family
- Cognitive function: Memory; speech; judgment; senses
- Rest/sleep patterns: Number of hours; naps; number of pillows; any aids for sleep
- Exercise patterns: Type and frequency
- Hobbies/recreation: Leisure activities; any travel outside of the US
- Social habits: Tobacco; alcohol; street drug use
- Intimate partner violence (review screening questions on page 58 in the Jarvis textbook)
- Coping/stress management: Any major life change in past 2 years; do you feel tense; source; what helps
- Sexual patterns: Are you sexually active; gender preference; has anything changed about your sexual health/function
III. Review of Symptoms
| Symptoms to Inquire About
(please see page 54–56 in Jarvis textbook) |
Document pertinent negatives and/or positives
The first system is addressed to provide a guide |
|
| General | Wgt Δ; weakness; fatigue; fevers
|
Pertinent negatives: No weight gain or losses; no weaknesses, fatigue, or fevers
Pertinent positives: Positive weight gain over past 2 months with fatigue and weakness; no fevers |
| Skin | Rash; lumps; sores; itching; dryness; color change; Δ in hair/nails | MN552 Advanced Health Assessment – SOAP Note Section II & III: History of Lifestyle Patterns and Review of Systems ROS |
| Head | Headache; head injury; dizziness or vertigo | |
| Eyes
|
Vision Δ; eye pain, redness or swelling, corrective lenses; last eye exam; excessive tearing; double vision; blurred vision; scotoma | |
| Ears | Hearing Δ; tinnitus; earaches; infections; discharge, hearing loss, hearing aid use | |
| Nose/
Sinuses |
Colds; congestion; nasal obstruction, discharge; itching; hay fever or allergies; nosebleeds; change in sense of smell; sinus pain | |
| Throat/
Mouth |
Bleeding gums; mouth pain, tooth ache, lesions in mouth or tongue, dentures; last dental exam; sore tongue; dry mouth; sore throats; hoarse; tonsillectomy; altered taste | |
| Neck | Lumps; enlarged or tender nodes, swollen glands; goiter; pain; neck stiffness; limitation of motion | |
| Breasts | Lumps; pain; discomfort; nipple discharge, rash, surgeries, history of breast disease; performs self-breast exams and how often, last mammogram; any tenderness, lumps, swelling, or rash of axilla area | MN552 Advanced Health Assessment – SOAP Note Section II & III: History of Lifestyle Patterns and Review of Systems ROS |
| Pulmonary | Cough — productive/non-productive; hemoptysis; dyspnea; wheezing; pleuritic pains; any H/O lung disease; toxin or pollution exposure; last Chest x-ray, TB skin test | |
| Cardiac | Chest pain or discomfort; palpitations; dyspnea; orthopnea; edema, cyanosis, nocturia; H/O murmurs, hypertension, anemia, or CAD | |
| G/I | Appetite Δ; jaundice; nausea/emesis; dysphagia; heartburn; pain; belching/flatulence; Δ in bowel habits; hematochezia; melena; hemorrhoids; constipation; diarrhea; food intolerance | |
| GU | Frequency; nocturia; urgency; dysuria; hematuria; incontinence
Females: Use of kegal exercises after childbirth; use of birth control methods; HIV exposure; Menarche; frequency/duration of menses; dysmenorrhea; PMS symptoms: bleeding between menses or after intercourse; LMP; vaginal discharge; itching; sores; lumps; menopause; hot flashes; post-menopausal bleeding; Males: Caliber of urinary stream; hesitancy; dribbling; hernia, sexual habits, interest, function, satisfaction; discharge from or sores on penis; HIV exposure; testicular pain/masses; testicular exam and how often |
|
| Peripheral Vascular | Claudication; coldness, tingling, and numbness; leg cramps; varicose veins; H/O blood clots, discoloration of hands, ulcers | |
| Musculo-skeletal | Muscle or joint pain or cramps; joint stiffness; H/O arthritis or Gout; limitation of movement; H/O disk disease | |
| Neuro | Syncope; seizures; weakness; paralysis; stroke, numbness/tingling; tremors or tics; involuntary movements; coordination problems; memory disorder or mood change; H/O mental disorders or hallucinations | |
| Heme | Hx of anemia; easy bruising or bleeding; blood transfusions or reactions; lymph node swelling; exposure to toxic agents or radiation | |
| Endo | Heat or cold intolerance; excessive sweating; polydipsia; polyphagia; polyuria; glove or shoe size; H/O diabetes, thyroid disease; hormone replacement; abnormal hair distribution | Unit_3_SOAP_GR |
| Psych | Nervousness/anxiety; depression; memory changes; suicide attempts; H/O mental illnesses | MN552 Advanced Health Assessment – SOAP Note Section II & III: History of Lifestyle Patterns and Review of Systems ROS |