NR 601 SOAP note
Week 2: Discussion Part Two8 8 unread replies. 34 34 replies. Physical examination:
Vital Signs
Height: 5 feet 2 inches Weight: 163 pounds BMI: 29.8 BP 150/86 T 98.0 po P 100 R 22, non-labored
HEENT: normocephalic, symmetric. Bilateral cataracts; PERRLA, EOMI; Upper and lower dentures in place a fitting well. No tinnitus. NR 601 SOAP note
NECK: Neck supple; non-palpable lymph nodes; no carotid bruits. Thyroid non-palpable
LUNGS: inspiratory crackles
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HEART: Normal S1 with S2 split during expiration. An S4 is noted at the apex; systolic murmur noted at the right upper sternal border without radiation to the carotids.
ABDOMEN: Normal contour; active bowel sounds all four quadrants; no palpable masses.
PV: Pulses are 2+ in upper extremities and 1+ in pedal pulses bilaterally. 2+ pitting edema to her knees noted bilaterally
GENITOURINARY: no CVA tenderness; not examined
MUSCULOSKELETAL: Heberden’s nodes at the DIP joints of all fingers and crepitus of the bilateral knees on flexion and extension with tenderness to palpation medially at both knees. Kyphosis and gait slow, but steady.
PSYCH: normal affect; her Mini-Cog Score is 3. Her PHQ-9 score is 22. NR 601 SOAP note
SKIN: Sparse hair noted on lower legs and feet bilaterally with dry skin on her ankles and feet.
NR 601 SOAP note Discussion Questions Part Two:
Post your SOAP note for this patient’s encounter.
Review the SOAP note format for the course. Summarize the history and results of the physical exam. Include one evidence-based journal article that supports your rationale for all diagnoses with ICD 10 codes and include a complete treatment plan that include medications, further diagnostics, patient education, referral and plan for follow-up. Each step of the plan must include an in-text citation to a scholarly source. Review the Reference Guidelines document in Course Resources. NR 601 SOAP note