Using nursing SOAP note for the following scenario.
Scenario: Ms. Sunshine a 60 year old Caucasian female is
complaining of recurrent muscle pain, migraine headaches, jaw and
facial tenderness. Ms. Sunshine reports that she has a pain level
of 10 in her legs as she hears a loud noise in the hallway that
made her pain worse. You observe her right knee, you notice its
inflammed and warm to the touch. Then she states, " I haven't been
able to properly clean up my house or go shopping like I normally
do because I start having pain and become very fatigued". The
medical assistant collected her vital signs: BP 132/84 mmHg T 98.0F
HR 104 bpm RR 22 bpm O2 Saturation 100% on room air She reports
that she has a health history of depression, anxiety, fibromyalgia,
chronic back pain, osteoarthritis, and vitamin D deficiency. She is
currently taking medications: Ibuprofen 800mg Vitamin D3 50,000U
Cymbalta 10mg Lyrica 25mg
Using nursing SOAP note for the following scenario. Scenario: Ms. Sunshine a 60 year old Caucasian female is complaining
-
- Site Admin
- Posts: 899603
- Joined: Mon Aug 02, 2021 8:13 am