*NURSING > SOAP NOTE > NSG6020_Week_6_SOAP_Note_ (All)

NSG6020_Week_6_SOAP_Note_

Document Content and Description Below

NSG6020_Week_6_SOAP_Note_ Age: 60 Sex: Female SUBJECTIVE CC: “I have pain in my right leg.” Reason given by the patient for seeking medical care “in quotes” HPI: Patient stat... es it began 3 days ago. The pain is in the right lower leg and she states that it also feels tight. The pain is a 7/10. Describe the course of the patient’s illness, including when it began, character of symptoms, location where the symptoms began, aggravating or alleviating factors; pertinent positives and negatives, other related diseases, past illnesses, surgeries or past diagnostic testing related to present illness. Medications: (list with reason for med ) None PMH No past medical history. Allergies: NKA Medication Intolerances: Denies Chronic Illnesses/Major traumas Denies Hospitalizations/Surgeries Denies “Have you every been told that you have: Diabetes, HTN, peptic ulcer disease, asthma, lung disease, heart disease, cancer, TB, thyroid problems or kidney disease or psychiatric diagnosis.” Family History Does your mother, father or siblings have any medical or psychiatric illnesses? Anyone diagnosed with: lung disease, heart disease, htn, cancer, TB, DM, or kidney disease. Mother had HTN, Father has CHF. Social History College graduate, married. Denies substance abuse. Education level, occupational history, current living situation/partner/marital status, substance use/abuse, ETOH, tobacco, marijuana. Safety status Denies ETOH, tobacco, marijuana. ROS General Weight change, fatigue, fever, chills, night sweats, energy level Denies weight change, fatigue, fever, chills, night sweats. Cardiovascular Chest pain, palpitations, PND, orthopnea, edema Denies chest pain, no palpitations, no orthopnea. Skin Delayed healing, rashes, bruising, bleeding or skin discolorations, any changes in lesions or moles Denies delayed healing, rashes, bruising, bleeding or skin discolorations, any changes or lesions or moles. Respiratory Cough, wheezing, hemoptysis, dyspnea, pneumonia hx, TB No cough, wheezing, hemoptysis, dyspnea, pneumonia. Eyes Corrective lenses, blurring, visual changes of any kind Does not wear glasses, no blurry vision, no visual changes of any kind. Gastrointestinal Abdominal pain, N/V/D, constipation, hepatitis, hemorrhoids, eating disorders, ulcers, black tarry stools No abdominal pain, N/V/D, constipation, hepatitis, hemorrhoids, eating disorders, ulcers, black tarry stools. Ears Ear pain, hearing loss, ringing in ears, discharge Denies ear pain, hearing loss, ringing in ears, discharge. Genitourinary/Gynecological Urgency, frequency burning, change in color of urine Denies frequency, burning, change in color of urine. Contraception, sexual activity, STDS Fe: last pap, breast, mammo, menstrual complaints, vaginal discharge, pregnancy hx Does not use contraception. Is sexually active with her husband. Denies STDs. Last pap was 2 years ago which was negative. Does not have menstrual periods. Denies pregnancy or vaginal discharge. Male: prostate, PSA, urinary complaints Nose/Mouth/Throat Sinus problems, dysphagia, nose bleeds or discharge, dental disease, hoarseness, throat pain Denies sinus problems, dysphagia, nose bleeds or discharge, dental disease, hoarseness, throat pain. Musculoskeletal Back pain, joint swelling, stiffness or pain, fracture hx, osteoporosis Denies back pain, there is swelling in the right lower leg with tightness and pain. No fracture or osteoporosis. Breast Admits to doing SBE monthly, denies any bumps or changes. SBE, lumps, bumps or changes Neurological Denies syncope, seizures, transient paralysis, weakness, paresthesias, black out spells. Syncope, seizures, transient paralysis, weakness, paresthesias, black out spells Heme/Lymph/Endo HIV status is negative. Denies bruising, blood transfusion hx, night sweats, swollen glands, increase thirst, increase hunger, cold or heat intolerance. HIV status, bruising, blood transfusion hx, night sweats, swollen glands, increase thirst, increase hunger, cold or heat intolerance Psychiatric Denies depression, anxiety, sleep issues, suicidal ideation/attempt. Depression, anxiety, sleeping difficulties, suicidal ideation/attempts, previous dx [Show More]

Last updated: 1 year ago

Preview 1 out of 5 pages

Reviews( 0 )

Recommended For You

 *NURSING> SOAP NOTE > NRP 531Tom Walker, Episodic SOAP Note: Already graded A. (All)

preview
NRP 531Tom Walker, Episodic SOAP Note: Already graded A.

Episodic SOAP Note: Tom Walker|NRP 531,Latest 2020 complete, Already graded A.

By Expert1 , Uploaded: Jul 18, 2020

$10

 *NURSING> SOAP NOTE > NURS 112 SOAP Note Chest Pain Pennsylvania State University -Download To Score An A (All)

preview
NURS 112 SOAP Note Chest Pain Pennsylvania State University -Download To Score An A

SOAP Note Chest Pain 1. Identifying data: Brain Foster is a 58-year-old Caucasian male. 2. Chief Complaint or Reason for Visit: he c/o having chest pain for 1 month. 3. History...

By Succeed , Uploaded: Aug 03, 2020

$9.5

 Health Care> SOAP NOTE > SOAP Note: Cardiovascular Patient: Liam Fitzgerald SUBJECTIVE CC: “Routine follow up for his chronic conditions” (All)

preview
SOAP Note: Cardiovascular Patient: Liam Fitzgerald SUBJECTIVE CC: “Routine follow up for his chronic conditions”

HPI: Mr. Fitzgerald is a 66-year-old male who presents via telehealth for a routine follow up on his chronic heart failure. He provided verbal consent for this telehealth visit. Mr. Fitzgerald repor...

By STUDY-GUIDENOTES , Uploaded: Oct 05, 2022

$7

 Health Care> SOAP NOTE > Caroline Casey SOAP (All)

preview
Caroline Casey SOAP

Caroline Casey SOAP

By Ellen Ronald , Uploaded: Jul 29, 2022

$8

 Health Care> SOAP NOTE > Episodic SOAP Note: Tom Walker|NRP 531,Latest2019/ 2020 complete, Already graded A (All)

preview
Episodic SOAP Note: Tom Walker|NRP 531,Latest2019/ 2020 complete, Already graded A

Running head: EPISODIC SOAP NOTE: TOM WALKER 1 Episodic SOAP Note: Tom Walker NRP 531 2021 Professor Sandra Brown EPISODIC SOAP NOTE: TOM WALKER 2 DOS: 4/15/2019 ID: Tom Walker (M) DOB: 6/28/73 (45) C...

By Nancylect , Uploaded: Jul 20, 2022

$9

 Health Care> SOAP NOTE > Episodic SOAP Note: Tom Walker|NRP 531,Latest 2019/ 2020 complete, Already graded A (All)

preview
Episodic SOAP Note: Tom Walker|NRP 531,Latest 2019/ 2020 complete, Already graded A

Running head: EPISODIC SOAP NOTE: TOM WALKER 1 Episodic SOAP Note: Tom Walker NRP 531 2021 Professor Sandra Brown EPISODIC SOAP NOTE: TOM WALKER 2 DOS: 4/15/2019 ID: Tom Walker (M) DOB: 6/28/73 (45) C...

By MARKALLAN , Uploaded: Jul 20, 2022

$9

 *NURSING> SOAP NOTE > Episodic SOAP Note: Tom Walker|NRP 531,Latest 2020 complete, Already graded A (All)

preview
Episodic SOAP Note: Tom Walker|NRP 531,Latest 2020 complete, Already graded A

Running head: EPISODIC SOAP NOTE: TOM WALKER 1 Episodic SOAP Note: Tom Walker NRP 531 2021 Professor Sandra Brown EPISODIC SOAP NOTE: TOM WALKER 2 DOS: 4/15/2019 ID: Tom Walker (M) DOB: 6/28/73 (45) C...

By Prof.Pierro , Uploaded: Jul 20, 2022

$9

 *NURSING> SOAP NOTE > ADULT 620 Week 4 make up SOAP note clinical patient (All)

preview
ADULT 620 Week 4 make up SOAP note clinical patient

ADULT 620 Week 4 make up SOAP note clinical patient Chief Complaint The patient presents in the clinic today with complaints of loss of voice 6 days ago, has rhinitis and congestion. Says has just...

By Topmentor , Uploaded: Jul 12, 2022

$10

 *NURSING> SOAP NOTE > BACTERIAL VAGINOSIS SOAP NOTE (All)

preview
BACTERIAL VAGINOSIS SOAP NOTE

BACTERIAL VAGINOSIS SOAP NOTE KL is a 25-year old female of a Caucasian decent

By Topmentor , Uploaded: Jul 12, 2022

$10

 *NURSING> SOAP NOTE > Week 6 SOAP note Patient Initials P.R. A 94 year old female (All)

preview
Week 6 SOAP note Patient Initials P.R. A 94 year old female

Week 6 SOAP note Patient Initials P.R. A 94 year old female Chief Complaint Follow-up from last week on peri-area rash. Patient states was in the hospital with a catheter, then in rehab was given ‘...

By Topmentor , Uploaded: Jul 12, 2022

$10

$11.00

Add to cart

Instant download

Can't find what you want? Try our AI powered Search

OR

GET ASSIGNMENT HELP
59
0

Document information


Connected school, study & course



About the document


Uploaded On

Mar 10, 2021

Number of pages

5

Written in

Seller


seller-icon
Expert

Member since 3 years

29 Documents Sold


Additional information

This document has been written for:

Uploaded

Mar 10, 2021

Downloads

 0

Views

 59

Document Keyword Tags

THE BEST STUDY GUIDES

Avoid resits and achieve higher grades with the best study guides, textbook notes, and class notes written by your fellow students

custom preview

Avoid examination resits

Your fellow students know the appropriate material to use to deliver high quality content. With this great service and assistance from fellow students, you can become well prepared and avoid having to resits exams.

custom preview

Get the best grades

Your fellow student knows the best materials to research on and use. This guarantee you the best grades in your examination. Your fellow students use high quality materials, textbooks and notes to ensure high quality

custom preview

Earn from your notes

Get paid by selling your notes and study materials to other students. Earn alot of cash and help other students in study by providing them with appropriate and high quality study materials.


$11.00

WHAT STUDENTS SAY ABOUT US


What is Browsegrades

In Browsegrades, a student can earn by offering help to other student. Students can help other students with materials by upploading their notes and earn money.

We are here to help

We're available through e-mail, Twitter, Facebook, and live chat.
 FAQ
 Questions? Leave a message!

Follow us on
 Twitter

Copyright © Browsegrades · High quality services·