SOAP Note Tina Jones

Greeting Tina Jones is a 28 year old African American female. She is single and lives with her mother. Tina is the primary source of her health is tree and has offered the information of her own free will. Tina speaks english and her speech is clear and coherent. During the interview Tina has maintained good eye contact. General Survey This is Tina Jones. She is a 28 year old, african american female. Tina appears to be well groomed and well dressed. Tina is alert and oriented to her surroundings. Tina weighs 90 kg and is 170 cm, with a BMI of 31. Tina's facial features are symmetrical with movement and there are no overall signs of acute distress. Based on appearance and body mass index Tina appears to be overweight. Tina's body parts appear to be equal bilaterally and are relevant in proportion to her body. Tina appears to have good posture and a sitting comfortably on the table. Rang of motion and gate seems normal. Tina has appropriate facial expressions mood and affect speech speech patterns and dress all seemed normal and appropriate for her age. S:    CC: “ Patient is in the office today for "scrape on my foot...it's looking pretty nasty. and the pain is killing me!" o EMPATHY!!!!!! HPI: o Onset: One week ago. o Location: plantar surface of right foot o Duration: o Characteristics/description: Reported that she tripped on the stairs while walking scrapping the ball of her foot. She has noted that o Aggravating factors: Walking and standing the wound has started oozing but denies odor. o Relieving factors: Tina stated that the “pain pills” relieve the pain for a short time. o Treatment: Tina sought treatment at the emergency deparment. Tine received a prescription for the pain medication Tamadol. Tina has been cleaning the laceration twice a day with soap and water as well as peroxide if it was “irritated”. She has used Neosporin and bandaged the area. o Current pain/pain at its worst (pain scale) Her current pain level is 7/10. Tina has reported that her pain was a 9/10 when she bears weight on the foot. o EDUCATION!!!! Current Meds: o What? Why?Dose,Frequency, Started when?Last time taken, Help the diagnosis?    ooooAllergies: ooooooPMH: ooooooooSocialooHx: ooooAllbuterol inhaler 90mcg/spray last used three days ago. Tina stated that she uses her inhaler PRN and has needed to use it two to three thimes a week recently.Tina is taking Tramadol 50 mg three times a day, last taken this morning around 830. Tina stated that this helps control the pain for a few hours. Tina takes Acetaminophen 500-1000 mg PO prn for hear headaches.Tina denies taking any supplements, herbs or viatamins on a daily bases. Tina uses Neosporine on her right foot. Tina take Advil 200mg PRN for menstral cramps.Any vitamins? Denies Supplements? Denies Herbs? Denies EDUCATION!!!!! And “Thank you for telling me about your meds...” Meds: PCN reaction rash and hives. Environmental: Tina is allergic to cats. She gets itchy eyes, sneezing and stated that her “asthma acts up” around them Latex: Tina denies a latex allergy. What happens? When discovered? How treated? When dx’d? Asthma at 2 1/2 years old, Diabetes at 24 years old How managed? Last “flare-up/episode” Describe symptoms Hospitalizations: Went to the ER one week ago for her injury to her right foot. Prior to that she has only been to the hospital for asthma attacks. The first Asthma attack was when she was 16 years old. Tina stated that she has been to the hospital “maybe five times total” for her asthma. Triggers/aggravating factors Sx EDUCATION/EMPATHY!!!! ESPECIALLY WITH T2DM/BLOOD SUGAR CHECKS, ETC. And “Thank you for telling me about your history...” Education level: Tina is in school for her Bachelor’s degree in Accounting. Living situation: Tina has recently moved back in with her mother following the death of Tina’s father. Stressors/current stress level: Tina stated “I feel pretty worried about my foot”, this is causing some stress in her life due missing school and work due to Religious affiliation: Tina is very active in her church. Activity level:  Regular exercise Occupation: Tina has works since highschool as a supervisor at Mid-American Copy and ship. She stated she works 32 hours a week and is sometimes flexed  Hrs worked