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Cranial Nerves, Thyroid, Neck, and Regional Lymphatics

Cranial Nerves, Thyroid, Neck, and Regional Lymphatics

Cranial Nerves, Thyroid, Neck, and Regional Lymphatics

 

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

 

 

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