soap note: Duodenal Ulcer – mynursingpaperwriters | Assignment Collections | assignmentcollections.com

Sample Soap Note:Soap Note # Main Diagnosis ( Exp: H&P Note #3 DX: Hypertension)Student NameMiami Regional UniversityDate of Encounter:Preceptor/Clinical Site:Clinical Instructor: Dr. Rafael CamejoSoap Note # Main Diagnosis ( Exp: Soap Note #3 DX: Hypertension)PATIENT INFORMATIONName: Mr. DTAge: 68-year-oldGender at Birth: MaleGender Identity: MaleSource: PatientAllergies: PCN, IodineCurrent Medications:ú Atorvastatin tab 20 mg, 1-tab PO at bedtimeú ASA 81mg po dailyú Multi-Vitamin Centrum SilverPMH: HypercholesterolemiaImmunizations: Influenza last 2018-year, tetanus, and hepatitis A and B 4 years ago.Preventive Care: Coloscopy 5 years ago (Negative)Surgical History: Appendectomy 47 years ago.Family History: Father- died 81 does not report informationMother-alive, 88 years old, Diabetes Mellitus, HTNDaughter-alive, 34 years old, healthySocial History: No smoking history or illicit drug use, occasional alcoholic beverage consumption on social celebrations. Retired, widow, he lives alone.Sexual Orientation: StraightNutrition History: Diets off and on, Does not each seafoodSubjective Data:Chief Complaint: ?headaches? that started two weeks agoSymptom analysis/HPI:The patient is 65 years old male who complaining of episodes of headaches and on 3 different occasions blood pressure was measured, which was high (159/100, 158/98 and 160/100 respectively). Patient noticed the problem started two weeks ago and sometimes it is accompanied by dizziness. He states that he has been under stress in his workplace for the last month. Patient denies chest pain, palpitation, shortness of breath, nausea or vomiting.Review of Systems (ROS)CONSTITUTIONAL: Denies fever or chills. Denies weakness or weight loss. NEUROLOGIC: Headache and dizziness as describe above. Denies changes in LOC. Denies history of tremors or seizures.HEENT: HEAD: Denies any head injury, or change in LOC. Eyes: Denies any changes in vision, diplopia or blurred vision. Ear: Denies pain in the ears. Denies loss of hearing or drainage. Nose: Denies nasal drainage, congestion. THROAT: Denies throat or neck pain, hoarseness, difficulty swallowing.RESPIRATORY: Patient denies shortness of breath, cough or hemoptysis.CARDIOVASCULAR: No chest pain, tachycardia. No orthopnea or paroxysmal nocturnaldyspnea.GASTROINTESTINAL: Denies abdominal pain or discomfort. Denies flatulence, nausea, vomiting ordiarrhea.GENITOURINARY: Denies hematuria, dysuria or change in urinary frequency. Denies difficulty starting/stopping stream of urine or incontinence.MUSCULOSKELETAL: Denies falls or pain. Denies hearing a clicking or snapping sound.SKIN: No change of coloration such as cyanosis or jaundice, no rashes or pruritus.Objective Data:VITAL SIGNS: Temperature: 98.5 øF, Pulse: 87, BP: 159/92 mmhg, RR 20, PO2-98% on room air, Ht- 6?4?, Wt 200 lb, BMI 25. Report pain 2/10.GENERAL APPREARANCE: The patient is alert and oriented x 3. No acute distress noted. NEUROLOGIC: Alert, CNII-XII grossly intact, oriented to person, place, and time. Sensation intact to bilateral upper and lower extremities. Bilateral UE/LE strength 5/5.HEENT: Head: Normocephalic, atraumatic, symmetric, non-tender. Maxillary sinuses no tenderness. Eyes: No conjunctival injection, no icterus, visual acuity and extraocular eye movements intact. No nystagmus noted. Ears: Bilateral canals patent without erythema, edema, or exudate. Bilateral tympanic membranes intact, pearly gray with sharp cone of light. Maxillary sinuses no tenderness. Nasal mucosa moist without bleeding. Oral mucosa moist without lesions,. Lids non-remarkable and appropriate for race.Neck: supple without cervical lymphadenopathy, no jugular vein distention, no thyroid swelling or masses.CARDIOVASCULAR: S1S2, regular rate and rhythm, no murmur or gallop noted. Capillary refill
 

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