NR 509 Tina Jones SOAP Note Shadow Health -with 100% verified solutions 2026-2027 SOAP Note (12pages)

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 hasstarted 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?