Unit 2 SOAP Note Section I Written Guide
History, Interview, and Genogram Guide
Please select a volunteer friend or family member to interview and gather data to complete this Assignment. The following guide will assist you in gathering subjective data in an organized, systematic manner to prevent omission of important components of the health history. Please remember to attach a Genogram with this Assignment as one document, if possible. You may search the web to locate a suitable Genogram diagram to input data. Only include 3 generations in the genogram depiction.
Date of History/Interview:
Source of history and Reliability: (client, family member, chart/record, etc. sample on page 50 of Jarvis textbook)
5225 Figueroa Mountain Road, Los Olivos, California
Joshua J. Taube, Vice President of Borrowers
21-1-1964 (55 years)
Gary, Indiana, United States
Black/ African Origin
Post-secondary: Bachelor’s Degree
Preferred Provider Organizations (PPOs)
In his words, F. M. B describes the pain as “retro-sternal, pressure-like, and radiating.”
P – Provocative or palliative (What brings it on? What makes it better or worse?)
According to F. M. B, the abrupt onset of chest pain can occur at any time of the day. However, whenever he is engaging in physical exercise, they are prone to occur. Two days ago, he had a 25-minute episode of pain when he was working in the garden. Today in the morning, he had 15-minute episode while his cat. Whenever type pain episodes occur, F. M. B retires to a cool area for rest. Other than rest, he has never tried any specific measure to relieve the pain.
Q – Quality or quantity (Describe the character and location of the symptoms; How does it look, feel, sound?)
R – Region or radiation (Where is it? Does the symptom radiate to other areas of the body?).
The pain emanates from the left para-sternal area of the chest. Within no time, the pain radiates up to the neck.
S – Severity (Ask the patient to quantify the symptom(s) on a scale of 0-10).
T – Timing (Inquire about the time of onset, duration, frequency, etc.)
The pain can occur during any time of the day, but mostly whenever he is working. He says that the chest pain episodes last between 5 minutes and 3 hours.
U – Understand Patient’s Perception of the problem (What do you think it means?)
From the assessment of F. M. B description of the problem and the symptoms, it is right to say that he might be suffering from myocardial infarction and unstable angina.
For the last 12 years, he has had Type 2 diabetes. In 2005, he suffered from ischemic heart disease. Last, he was diagnosed with hypertension. In 1992, he was diagnosed with total abdominal hysterectomy and bilateral oophorectomy. Three years later, he was diagnosed with bunionectomy.
He says he does not remember his childhood illness.
He has never been diagnosed and treated with any mental illness.
He is allergic to penicillin. In 1894, he experienced rashes and hives after consuming penicillin.
On March 6, 2018, F. M. B had a funduscopic exam. The examination revealed normal vessels and tympanic membranes.
Two brothers died following a myocardial infarction one at age 36 and the other at age 55. Both father and mother have a history of hypertension and ischemic heart disease.