Nursing > SOAP NOTE > Walden University - NURSING: NURS6512 Health Assessment Week 8 discussion: SOAP NOTE Case Study Ankl (All)
SOAP NOTE Ankle Pain Patient Initials: __MH___ Age: _46____ Gender: __F____ SUBJECTIVE DATA: Chief Complaint (CC): Ankle pain bilaterally History of Present Illness (HPI): MH is a 46-y... ear-old Caucasian female who presents today with bilateral ankle pain, with worse pain in the right ankle. The pain started after playing soccer over the weekend when she heard a “pop”. She reports that she is able to bear weight, but it is uncomfortable. She has taken Ibuprofen and Tylenol for swelling and pain that helps a little. She rated the severity of pain in her left ankle as a 2/10 and a 6/10 in the right ankle. Medications: 1.) Multivitamin daily 2.) Ibuprofen 200mg-2 PO as needed 3.) Tylenol 325mg-2 PO every 4 hours as needed Allergies: NKA Past Medical History (PMH): 1.) Asthma – when she was a child 2.) Right ankle sprain - 2015 Past Surgical History (PSH): 1.) Cholecystectomy 2000 2.) Wisdom teeth extraction 1990 Sexual/Reproductive History: Heterosexual G1P1A0 Menopausal – started 2014 Personal/Social History: She drinks occasionally; denied denies smoking or illicit drug use. Immunization History: Her immunizations are up to date. She received the influenza vaccine last October, and had a tetanus shot two years ago when she cut her arm on a piece of metal. Significant Family History: One brothers with hypertension, dx at age 50. She has one son in her 20s, healthy, living at home. Lifestyle: She is a secretary, lives with her husband and son in a nice neighborhood with a low crime rate. She belongs to a local YMCA and says she goes there 4 to 5 days a week to exercise. She has a primary care nurse practitioner provider and goes for her yearly checkups and when she is sick. She has a pap smear done yearly and had her last mammogram a couple months ago. She has a healthy diet and eating pattern. She has a good support system composed of family and friends. Review of Systems: General: Pleasant 46-year-old female sitting in chair talking comfortably. Does not appear to be anxious at this time. Good historian Reference Ball, J. W., Dains, J. E., Flynn, J. A., Solomon, B. S., & Stewart, R. W. (2015). Seidel's guide to physical examination (8th ed.). St. Louis, MO: Elsevier Mosby. Healthline. (2015). Ankle sprain. Retrieved from http://www.healthline.com/health/ankle-sprain#Overview1 Lowth. M. (2016). Ankle fractures. Retrieved from http://patient.info/doctor/ankle-fractures Ortho Info. (2010). Achilles tendinitis. Retrieved from http://orthoinfo.aaos.org/topic.cfm?topic=a00147 Orthopod. (2016). Peroneal tendon subluxation. Retrieved from http://eorthopod.com/peroneal-tendon-subluxation/ Reuss, B., L. (2015). Calcaneofibular ligament injury clinical presentation. Retrieved from http://emedicine.medscape.com/article/85526-clinical [Show More]
Last document update: 11 months ago
Preview 1 out of 6 pages
Connected school, study & course
About the document
11 months ago
Number of pages
This document has been written for:
11 months ago
Avoid resits and achieve higher grades with the best study guides, textbook notes, and class notes written by your fellow students
Your fellow students know the appropriate material to use to deliver high quality content. With this great service and assistance from fellow students, you can become well prepared and avoid having to resits exams.
Your fellow student knows the best materials to research on and use. This guarantee you the best grades in your examination. Your fellow students use high quality materials, textbooks and notes to ensure high quality
Get paid by selling your notes and study materials to other students. Earn alot of cash and help other students in study by providing them with appropriate and high quality study materials.
Florida State University
Great tool for learning! I wish you success.
Louisiana State University
I love this site, they make everything so easy
G D Goenka University
It is helpful Platform for offering the notes
University of Windsor
University Of South Florida
Great! It is a good place to share knowledge.
Thank you so much for this nice platform.
Florida State University
Awesome and a great way to make money!
It is an excellent site to post assignment.
Great way to get paid for all of the hard work!
In Browsegrades, a student can earn by offering help to other student. Students can help other students with materials by upploading their notes and earn money.
Copyright © Browsegrades · High quality services·