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NSG 6020 Soap Note – Angina Pectoris or Acute MI Diagnosis
NSG 6020 Soap Note – Angina Pectoris or Acute MI Diagnosis
SOAP NOTE
| Name: T. H. | 7/21/ | Time: 9:00 am | ||
| Age: 47 | Sex: Female | |||
| SUBJECTIVE | ||||
| CC:
“I’m here because my left arm feels funny and tingles all the time”.
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| HPI:
Mrs. H. is 47 year old female patient presenting to the office today for with left arm tingling and numbness. She had a recent visit to the ER due to BLE edema. She was given Lasix and her lab work showed several electrolyte imbalances. She states that she has also had chest pain throughout the week. Her last office visit consisted of an evaluation and lab work to evaluate her thyroid status. She denies any fever, diaphoresis, shortness of breath or chest pain. |
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| Medications:
Magnesium oxide 400 mg 1 tab by mouth daily Potassium Chloride 10 meq capsule daily Levothyroid 125 mcg tab daily. NSG 6020 Soap Note – Angina Pectoris or Acute MI Diagnosis Lisinopril hydrochlorothiazide 20-12.5 mg tablet daily Lipitor 40 mg daily Ultram 50 mg every six hours as needed for pain |
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| PMH
Allergies: Sulfa Medication Intolerances: Sulfa antibiotics Chronic Illnesses/Major traumas Hypothyroidism Chronic Health Problems:
Hospitalizations/Surgeries Cholecystectomy Tubal ligation Left knee Arthroscopy Other: Immunizations: unknown Environmental hazards: Denies any environmental hazards. Able to perform ADLs without difficulty. Safety measures: Stated not discussed Exercise and leisure: She gets short of breath with strenuous activities. Sleep: Tries to get at least 6 hours of sleep every night. Diet: Admits to unhealthy eating habits. |
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| Family History
Did not provide information |
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| Social History
She drinks socially. Denies smoking. Denies illicit drugs. NSG 6020 Soap Note – Angina Pectoris or Acute MI Diagnosis |
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| ROS | ||||
| General
Admits frequent fatigue. Denies fever, night sweats or recent weight gain or loss. |
Cardiovascular
Occasional chest pain. No murmur, bruits, palpitations, or edema. |
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| Skin
Skin intact. No lesions noted. Denies any rash or itching. |
Respiratory
Denies cough. Denies hemoptysis, wheezing, or exposure to TB. Admits to SOB on exertion. |
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| Eyes
Denies complaints of blurred vision or visual disturbances reported. |
Gastrointestinal
Denies abdominal pain, nausea, vomiting, dysphagia or abnormal stools. |
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| Ears
Denies hearing loss discharge or ear pain. |
Genitourinary/Gynecological
Denies any frequency, hesitancy, nocturia or urgency. |
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| Nose/Mouth/Throat
Denies dryness, hoarseness, or mouth pain. |
Musculoskeletal
Denies pain. |
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| Breast
SBE, lumps, bumps or changes |
Neurological
Denies syncope or headache, focal weakness, numbness, paresthesia’s, tremors, gait instability, falls or memory loss. NSG 6020 Soap Note – Angina Pectoris or Acute MI Diagnosis |
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| Heme/Lymph/Endo: Denies easy bruising, bleeding, or blood clots. Denies increased hunger or thirst. Denies recent weight loss. Denise night sweats or swollen glands. | Psychiatric
Denies any anxiety or suicidal ideations |
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| OBJECTIVE | ||||
| Weight 198 lbs BMI 34.0 | Temp 98.6 | BP 128/72 | ||
| Height 5’4” | Pulse 52 | Resp 16 | ||
| General Appearance
This is a pleasant 47 year old Caucasian female that presents in mild distress. |
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| Skin
No cyanosis or clubbing noted. No rashes or lesions noted. |
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| HEENT
Head: Head is normocephalic, no tenderness during palpation. Eyes: PERRLA (3 mm) Ears: External auditory canals with some cerumen and fluid noted bilaterally. Tympanic membranes intact, pearly gray with light reflex noted. Nose: Nasal mucosa moist without drainage, septum midline. Neck: Supple. Full ROM. No lymphadenopathy; no occipital nodes. No thyromegaly or nodules or masses palpated. Oral mucosa pink and moist. Trachea midline. |
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NSG 6020 Week 5 SOAP Note Assignment
SOAP Note
Each week you are required to enter your patient encounters into CORE. Your faculty will be checking to ensure you are seeing the right number and mix of patients for a good learning experience. Beginning in Week 5, you will need to include one complete SOAP note each week through Week 9 for a total of 5 complete SOAP notes for this course using this SOAP note template. The SOAP note should be related to the content covered in this week, and the completed SOAP note should be submitted to the Submissions Area. When submitting your note, be sure to include the reference number from CORE where you entered this specific patient’s case entry. NSG 6020 Soap Note – Angina Pectoris or Acute MI Diagnosis
Submission Details:
By the due date assigned, enter your patient encounters into CORE and complete at least one SOAP note in the template provided.
Name your SOAP note document SU_NSG 6020_W5_A2_LastName_FirstInitial.doc.
Include the reference number from CORE in your document.
Submit your document to the Submissions Area by the due date assigned.
NSG 6020 Week 6 SOAP Note Assignment
SOAP Note
Each week you are required to enter your patient encounters into CORE. Your faculty will be checking to ensure you are seeing the right number and mix of patients for a good learning experience. Beginning in Week 5, you will need to include one complete SOAP note each week through Week 9 for a total of 5 complete SOAP notes for this course using this SOAP note template. The SOAP note should be related to the content covered in this week, and the completed SOAP note should be submitted to the Submission Area. When submitting your note, be sure to include the reference number from CORE where you entered this specific patient’s case entry.
Submission Details:
By the due date assigned, enter your patient encounters into CORE and complete at least one SOAP note in the template provided.
Name your SOAP note document SU_NSG 6020_W6_A4_LastName_FirstInitial.doc.
Include the reference number from CORE in your document.
Submit your document to the Submissions Area by the due date assigned.
NSG 6020 Week 6 Physical Exam Video and Write Up Assignment
Complete Health History and Physical Assessment Write-Up Presentation
This assignment consists of complete head to toe physical while being videoed. You will also need to complete a written assignment of your findings. Review the Expanded rubric to note how you will be graded on this assignment.
NSG 6020 Week 7 SOAP Note Assignment
Each week you are required to enter your patient encounters into CORE. Your faculty will be checking to ensure you are seeing the right number and mix of patients for a good learning experience. Beginning in Week 5, you will need to include one complete SOAP note each week through Week 9 for a total of 5 complete SOAP notes for this course using this SOAP note template. The SOAP note should be related to the content covered in this week, and the completed SOAP note should be submitted to the Submissions Area. When submitting your note, be sure to include the reference number from CORE where you entered this specific patient’s case entry.
Submission Details:
By the due date assigned, enter your patient encounters into CORE and complete at least one SOAP note in the template provided.
Name your SOAP note document SU_NSG 6020_W7_A3_LastName_FirstInitial.doc.
Include the reference number from CORE in your document.
Submit your document to the Submissions Area by the due date assigned.
NSG 6020 Week 8 SOAP Note Assignment
SOAP Note
Each week you are required to enter your patient encounters into CORE. Your faculty will be checking to ensure you are seeing the right number and mix of patients for a good learning experience. Beginning in Week 5, you will need to include one complete SOAP note each week through Week 9 for a total of 5 complete SOAP notes for this course using this SOAP note template. The SOAP note should be related to the content covered in this week, and the completed SOAP note should be submitted to the Submissions Area. When submitting your note, be sure to include the reference number from CORE where you entered this specific patient’s case entry.
Submission Details:
By the due date assigned, enter your patient encounters into CORE and complete at least one SOAP note in the template provided.
Name your SOAP note document SU_NSG 6020_W8_A3_LastName_FirstInitial.doc.
Include the reference number from CORE in your document.
Submit your document to the Submissions Area by the due date assigned.
NSG 6020 Week 9 SOAP Note Assignment
SOAP NOTE
Each week you are required to enter your patient encounters into CORE. Your faculty will be checking to ensure you are seeing the right number and mix of patients for a good learning experience. Beginning in Week 5, you will need to include one complete SOAP note each week through Week 9 for a total of 5 complete SOAP notes for this course using this SOAP note template. The SOAP note should be related to the content covered in this week, and the completed SOAP note should be submitted to the Submissions Area. When submitting your note, be sure to include the reference number from CORE where you entered this specific patient’s case entry.
Submission Details:
By the due date assigned enter your patient encounters into CORE and complete at least one SOAP note in the template provided.
Name your SOAP note document SU_NSG 6020_W9_A3_LastName_FirstInitial.doc.
Include the reference number from CORE in your document.
Submit your document to the Submissions Area by the due date assigned.