Discussion week 7
Episodic/Focused SOAP Note
12 years, F, A
CC (Chief complaint) – Abdominal pain
Location: Right lower quadrant
Onset: 3 evenings
Character: Abdominal pain with malaise
Associated signs and symptoms: Nausea, vomiting, low appetite, fever
Timing: The pain has been progressive since onset
Relieving factors: Taking acetaminophen and ipobrufen and lots of water.
Severity: 7/10 pain scale
Current Medications: The patient has had acetaminophen and ipobrufen.
PMHx: Malaria three months ago treated using Chloroquine after a trip to Nigeria
Soc Hx: The patient likes to spend time with friends and partying. She also enjoys travelling and accompanies the father to some of his international trips. The patient stays with both parents and claims to have a hygienic environment at home. Her mother is a quality assurance officer at a hotel and is keen about hygiene. She is under no exposure to drugs whatsoever.Fam Hx: The patient’s family has a history of sensitive gut on her mother’s side; a reason why the mother is very keen on hygiene.
GENERAL: Fever present. Feelings of unease and fatigue
HEENT: Eyes: No blurred vision, double vision or visual loss. Ears, Nose, Throat: no hearing loss, no sore throat or running nose.
SKIN: The patient has a skin tan. The tan is uniform.
CARDIOVASCULAR: The patient does not experience any chest pain or discomfort.
RESPIRATORY: The patient h…
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