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)

1. Biographical Data
   1. Name (use initials only)
   2. M. B
   3. Address

5225 Figueroa Mountain Road, Los Olivos, California

1. Phone number

+1-541-754-3017

1. Primary language

English

1. Authorized representative

Joshua J. Taube, Vice President of Borrowers

1. Age and Date of Birth

21-1-1964 (55 years)

1. Place of Birth

Gary, Indiana, United States

1. Gender

Male

1. Race

Caucasian

1. Marital Status

Married

1. Ethnic/Cultural Origin

Black/ African Origin

1. Education ( highest level completed)

Post-secondary: Bachelor’s Degree

1. Occupation/Professional

Lawyer

1. Health insurance

Preferred Provider Organizations (PPOs)

2. Chief Complaint (reason for seeking health care):
3. M. B has been experiencing an abrupt onset of chest pain that begun in the left para-sternal area of and radiated up to his neck. He has also been experiencing shortness of breath.
   1. A brief, spontaneous statement in the client’s own words

In his words, F. M. B describes the pain as “retro-sternal, pressure-like, and radiating.”

1. Includes when the problem started ( “chest pain for 2 hours”)
2. M. B explains that he has been experiencing episodes of chest pain for the last one week.

3. History of Present Illness: A well-organized, chronological record of the client’s reason for seeking care, from the time of onset to present. Please include the 8 critical characteristics using the PQRSTU pneumonic.

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?)

1. M. B describes the pain as pressure-like. He says that sometimes the pain is mild which result in a burning and sharp sensation.

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).

6. M. B explains that the severity of the pain varies with every single episode. However, on a scale of 0-10, he indicates that the severity averages at 6. There is always associated with shortened breath.

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.

 

4. Past Medical History
   1. Medical Hx: major illnesses during the life span, injuries, hospitalizations, transfusions, and disabilities

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.

1. Childhood Illnesses: Measles, mumps, rubella, chickenpox, pertussis, strep throat.

He says he does not remember his childhood illness.

1. Surgical Hx; procedures, dates, inpatient or outpatient
2. M. B has never had a surgical operation all his life.
3. Obstetric HX: Number of pregnancies, term deliveries, preterm births, abortions (spontaneous or induced), number of children living

N/A

1. Immunizations
2. M. B has been immunized against the following diseases, anthrax, measles, mumps, and chickenpox.
3. Psychiatric Hx: childhood and adult (treated or hx of)

He has never been diagnosed and treated with any mental illness.

1. Allergies: Medications, food, inhalants or other (what occurs with reaction)

He is allergic to penicillin. In 1894, he experienced rashes and hives after consuming penicillin.

1. Current Medications: Include all prescription, herbal/supplements and OTC, dosage, frequency
2. M. B has been taking antidiabetic and antihypertensive drugs. He has also been taking diclofenac MR and Nifedipine tablets.
3. Last Examination Date: Physical, eye exam, foot exam, dental exam, hearing screen, EKG, chest X-Ray, Pap test, mammogram, serum cholesterol, stool occult blood, prostate, PSA, UA, TB skin test; other health maintenance tests for infants/children may include sickle-cell, PKU, lead level, and hematocrit

On March 6, 2018, F. M. B had a funduscopic exam. The examination revealed normal vessels and tympanic membranes.

5. Family History (list FHx and design a genogram (computer)-include a key with the genogram). The Genogram must include 3 generations.
   1. Include parents, grandparents, spouse, and children.
   2. Health conditions, familial and communicable diseases/illnesses
   3. Note whether family member deceased or living

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.