NU 6541 WK 3 SOAP -Primary Care
NU 6541 WK 3 SOAP -Primary Care of Adolescents and Children
Week 3 SOAP note- Follow up Evaluation
Patient Initials: ___AH____ Age: ___12____
Gender: ___F____
SUBJECTIVE DATA:
Chief Complaint (CC): Episodes of altered mental status, follow
up from recent hospitalization
History of Present Illness (HPI): 12-year-old African American
female brought to clinic with mother for follow up evaluation after
hospitalization. Two days prior, patient was at school with she
became altered and had episodes of jerking movements. …
Medications:
…
Imipramine 25mg PO PRN- Mother reports that she occasionally
takes this is she drinks a lot prior to bed. Last dose was 1 week
prior to event occurring.
Trazodone PRN
Allergies: NKDA
Past Medical History (PMH):

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