UOPX Material - University of Phoenix
University of Phoenix Material
SOAP Note I
G.S. is a 16-year-old, white female who came in with her mother. G.S. complains of weekly, intermittent headaches that began 2 months ago and are described as moderate to severe. Headaches are right temporal and last from 4-8 hours with occasional nausea when severe. Headaches occur at different times of the day, and are most often preceded by blurred vision that lasts from 30-45 minutes. Blurred vision clears and the headache slowly begins, progressing to severe pounding headaches with occasional photophobia. G.S. takes Tylenol 500 mg po prn and goes into a darkened room to sleep after which she wakes up feeling well. This happens 1-2 times a week and she has missed about 2 days of school in the last 2 months. G.S. has 2 maternal aunts with similar problems. Height – 63”, weight – 116 pounds. Temp 99, HR 72, RR 18, BP 112/70. Exam is benign.
SOAP Note II
Mrs. Epstein and her 11-year-old son, Bart, went to the pediatric clinic with the complaint of sore throat that has lasted for 3 days along with headache, fatigue, and abdominal discomfort. Bart has taken ibuprofen for his fever and headache. Mrs. Epstein did not take Bart’s temperature, however, he felt hot. Height – 54”, Weight – 80 pounds. Temp 101, HR 88, RR 20, BP 108/70. When you enter the room, Bart is slouched on the chair falling asleep. On exam you find that he has clear drainage from his nose; erythematous, exudates on tonsils, palpable posterior and anterior cervical nodes as well as occipital and epitrochlear nodes. Spleen enlarged 2 cm below LCM with pain on palpation of LUQ.
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