MN552 Advanced Health Assessment

MN552 Advanced Health Assessment

Unit 2 SOAP Note Section I Written Guide

History, Interview, and Genogram Guide

Date of History/Interview: 23rd, September, 2017

Source of history and Reliability: (client)

  1. Biographical Data
    1. Name (use initials only): W.W.
    2. Address: George street, House no. 4, California
    3. Phone number 305-555-5555
    4. Primary language: speaks English
    5. Authorized representative: her daughter
    6. Age and Date of Birth: 50 y/o, July 15, 1967
    7. Place of Birth: San Diego, California
    8. Gender: female
    9. Race: black
    10. Marital Status: divorced
    11. Ethnic/Cultural Origin: African
    12. Education: master’s in criminology
    13. Occupation/Professional: lecturer
    14. Health insurance: full medical coverage
  1. Chief Complaint (reason for seeking health care):
    1. 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.”

  1. Includes when the problem started

“I started coughing like three months ago. I have undergone treatment from regular hospitals but nothing seems to change.”

  1. 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.

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.

  1. Past Medical History
    1. 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.

  1. Childhood Illnesses: Measles, chickenpox, Mumps, strep throat
  2. Surgical Hx; dates, outpatient, X-rays.

Vaginal delivery on 02/26/1987, Chest X ray 08/15/2017

  1. Obstetric HX:

Only one pregnancy, and one delivery, she gave birth to her daughter who is the only child.no miscarriages or abortion cases.

  1. 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.
  2. Psychiatric Hx: no psychiatric conditions reported.
  3. Allergies: allergic to dust
  4. Current Medications: Metformin 500mg BID for diabetes type 2.
  5. Last Examination Date: 12th March, 2017

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.

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