Olivet Nazarene UniversityNRSG MISCSimmons_Stefanie_SOAP Note_Week 7_HA1.

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Running head: SOAP NOTE 1 Week Seven SOAP Note: Advanced Health Assessment I Stefanie L. Simmons Olivet Nazarene University Certification of Authorship: I certify that I am the author of this pape... r and that any assistance I received in its preparation is fully acknowledged and disclosed in the paper. I have also cited any sources from which I used data, ideas, or words, either quoted directly or paraphrased. I also certify that this paper was prepared by me specifically for this assignment. Your Signature: Stefanie L. Simmons SOAP NOTE 2 SUBJECTIVE: CC: “I have ringing in my ears” HPI: Mr. S. reports an increasing issue with ringing in his ears. The ringing is continuous and has increased over the past year with the left seemingly louder than the right. The ringing first presented approximately five years ago. The only relief is using headphones with music to drown out the ringing, or to go to sleep. The patient reports when he is in a quiet room the ringing is unbearable. There are no associated issues with pain, dizziness, visual disturbances or anxiety. The patient is concerned about complete hearing loss. PMH: Childhood Illnesses: chickenpox Adult Illnesses: Seizure disorder Surgical History: Wisdom teeth extraction, 1997; right rotator cuff repair, 2014. Health Maintenance: Normal childhood vaccines are up to date. Tetanus booster was given in 2015. Declines flu vaccine. Family History: Father died at age 54 years in an accident. Mother is still living and has a history of hypertension and arthritis. The patient is an only child. There is a family history of diabetes, cancer and cardiac disease on the maternal side. Daughter age 15, well; daughter age SOAP NOTE 3 13, well; son age 4, well. No family history of anemia, tuberculosis, kidney disease, or mental illness. Social History: No smoking, no alcohol; no illicit drugs. Patient lives with a spouse, and three children who are all minors. [Show More]

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