Unit 4: Cranial Nerves, Thyroid, Neck, and Regional Lymphatics

Assignment 1: Comprehensive SOAP Note

This Assignment will help develop skills to perform an integrated history and physical examination for individuals across the lifespan.

Considerations of lifestyle practices, cultural/ethnic differences, and developmental variations will be incorporated into the plan of care. Use critical thinking and diagnostic reasoning skills      to formulate differential diagnoses, medical diagnoses, and an      evidence-based action plan. Include sections 1 and 2 of the SOAP note with      recommendations (incorrect or omitted data) based on feedback provided for      the previous sections of the SOAP note. Complete the Comprehensive SOAP Note.

MN552 Advanced Health Assessment 

Unit 4 Comprehensive SOAP Note Written Guide

SOAP Note Written Guide

This guide will assist you to document history data, and perform a comprehensive physical exam in an organized and systematic manner.Please include a heart exam and lung exam on all clients regardless of the reason for seeking care.So, if someone presented with cough and cold symptoms, you would examine the General appearance, HEENT, Neck, Heart and Lungs for a focused/episodic exam.However, this Assignment requires assessment of all body systems.The pertinent positive findings should be relevant to the chief complaint and health history data. Please follow the guide and include all previous sections of the SOAP Note with corrections based on feedback, as well as the Objective and Plan sections.

I. Subjective Data

A:Biographical Data 

B: Source of history and reliability

C:Chief Complaint

D:History of Present Illness (HPI)

E: Past Medical History

F:Family History

G:Social History (alcohol, drug, or tobacco use)

H.Lifestyle Patterns

I:Allergies

J:Current Medications

Review of Symptoms

  

Symptoms   to Inquire About

(please   see page 54–56 in Jarvis textbook)

Document   pertinent negatives and/or positives

The   first system is addressed to provide a guide

 

General

Wgt Δ; weakness;   fatigue; fevers

Pertinent   Negatives: No weight gain or losses; no   weaknesses, fatigue, or fevers

Pertinent   Positives:Positive weight gain over past 2 months   with fatigue and weakness; no fevers

 

Skin

Rash; lumps; sores;   itching; dryness; color change; Δ in hair/nails

 

Head

Headache; head injury;   dizziness or vertigo

 

Eyes

Vision Δ; eye pain,   redness or swelling, corrective lenses; last eye exam; excessive tearing;   double vision; blurred vision; scotoma

 

Ears

Hearing Δ; tinnitus;   earaches; infections; discharge, hearing loss, hearing aid use

 

Nose/

Sinuses

Colds; congestion;nasal   obstruction, discharge; itching; hay fever or allergies; nosebleeds;change in   sense of smell; sinus pain

 

Throat/

Mouth

Bleeding gums; mouth   pain, tooth ache, lesions in mouth or tongue, dentures; last dental exam;   sore tongue; dry mouth; sore throats; hoarse; tonsillectomy; altered taste

 

Neck

Lumps; enlarged or   tender nodes, swollen glands; goiter; pain; neck stiffness; limitation of   motion

 

Breasts

Lumps; pain;   discomfort; nipple discharge, rash, surgeries, history of breast disease;   performs self-breast exams and how often, last mammogram; any tenderness,   lumps, swelling, or rash of axilla area

 

Pulmonary

Cough—productive/non-productive;   hemoptysis; dyspnea; wheezing; pleuritic pains; any H/O lung disease; toxin   or pollution exposure; last Chest X-RAY, TB skin test

 

Cardiac

Chest pain or   discomfort; palpitations; dyspnea; orthopnea; edema, cyanosis, nocturia; H/O   murmurs, hypertension, anemia, or CAD

 

G/I

Appetite Δ; jaundice;   nausea/emesis; dysphagia; heartburn; pain; belching/flatulence; Δ in bowel   habits; hematochezia; melena; hemorrhoids; constipation; diarrhea; food   intolerance

 

GU

Frequency; nocturia;   urgency; dysuria; hematuria; incontinence

Females:   Use of kegal exercises after childbirth; use of birth control methods; HIV   exposure; Menarche; frequency/duration of menses; dysmenorrhea; PMS symptoms:   bleeding between menses or after intercourse; LMP; vaginal discharge;   itching; sores; lumps Menopause; hot flashes; post-menopausal bleeding;

MALES:caliber of   urinary stream; hesitancy; dribbling; hernia, Sexual habits; interest;   function; satisfaction; Discharge from or sores on penis; HIV exposure;   testicular pain/masses; testicular exam and how often

 

Peripheral   Vascular

Claudication; coldness,   tingling, and numbness; leg cramps; varicose veins; H/O blood clots,   discoloration of hands, ulcers

 

Musculo-skeletal

Muscle or joint pain or   cramps; joint stiffness; H/O arthritis or Gout; limitation of movement; H/O   disk disease

 

Neuro

Syncope; seizures;   weakness; paralysis; stroke, numbness/tingling; tremors or tics; involuntary   movements; coordination problems;memory disorder or mood change; H/O mental   disorders or hallucinations

 

Heme

Hx of anemia; easy   bruising or bleeding; blood transfusions or reactions; lymph node swelling;   exposure to toxic agents or radiation

 

Endo

Heat or cold   intolerance; excessive sweating; polydipsia; polyphagia; polyuria;glove or   shoe size; H/O diabetes, thyroid disease; or hormone replacement; abnormal   hair distribution

 

Psych

Nervousness/anxiety;   depression; memory changes; suicide attempts;H/O mental illnesses

II.Objective Data

  

General:

 

Skin:

 

HEENT & Sinuses:

 

Neck & Regional Lymph Nodes:

 

Breasts:

 

Lungs & Thorax:

 

Heart:

 

Gastrointestinal:

 

Genitourinary:

 

Extremities (Peripheral Vascular):

 

Musculoskeletal:

 

Neurological:

III.Assessment

A: Differential Diagnosis (include rationales and cite sources)

1.

2.

3.

B:Nursing Diagnosis

1.

C:Medical Diagnosis

IV. PLAN

A:Orders

1. Prescriptions with dosage, route, duration, and amount prescribed and if refills provided

2. Diagnostic testing

3. Problem oriented education

4. Health Promotion/Maintenance Needs

B:Follow-Up Plans (When will you schedule a follow-up appointment and what will you address in the subsequent visit —F/U in 2 weeks; Plan to check annual labs on RTC(return to clinic).

V.Nursing Theory & Application: Select a Nursing Theory and apply this to your patient’s plan and evaluation (brief statement).

VI.Developmental Stage:Identify the developmental state and provide rational to support acquisition of skills in the stage (brief statement).

VII.Cultural Characteristics, Diversity, Sensitivity & Ethical Considerations

Discuss culturally diverse considerations you identified for this patient.Cultural Diversity is a general term that can include gender, religious beliefs, culture, race, economic status, age, and etc.Discuss one ethical standard relevant to the care of this patient.

VIII.Evaluation of Care:Provide a brief statement sharing your thoughts about the visit and/or patient.Please share what you should have done differently.

References:Please include a minimum of three references.The reference list must be in APA format.All sources must be within 5 years of publication.