NR 603 Wk 7 Soap Note Format.docx - Melaine Ndi NR 603 Wk 7 SOAP Note Format \u2013 Laura Patient Information Laura 50y\/o Caucasian Female S CC \u2013

NR 603 Wk 7 Soap Note Format.docx - Melaine Ndi NR 603 Wk 7...

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Melaine Ndi NR 603 Wk 7 SOAP Note Format – Laura Patient Information: Laura, 50y/o Caucasian Female S. CC – “ fatigue HPI : Pt presenting to clinic with c/o decreased appetite and nausea x3 weeks. Endorses 5lb weight loss and change in skin color having “a funny tinge to it”. Also endorses occasional muscle aches and stomach cramps , and takes Ibuprofen for the aches and pains. Pt denies any fever. Current Medications : Daily MVT Fish oil Ibuprofen prn CoQ 10 (need daily dose - research has detected elevated levels of liver enzymes in people taking doses of 300 mg per day for long periods of time). Allergies: PCN - rash PMHx: Chicken pox PSHx: Cholecystectomy Bilateral tubal ligation Hospitalizations: Childbirth x2 Immunizations: Does not receive the flu shot . Blood transfusions: None Social Hx: Divorced for 2 years, dating for 1 year. She is sexually active with 2 partners in the last 6 months. Does not use condoms, had a bilateral tubal ligation 10 years ago. ETOH, tobacco,
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illicit drugs. She drinks alcohol socially, does not smoke, denies illicit drug use. Sleeps 6 to 8 hours per night. Family Hx: Non contributory ROS : CONSTITUTIONAL: Endorses 5lb weight loss. How long did it take to lose 5lbs? Any recent fever/malaise/chills/? Have you had any recent exposure to sick contacts? Have you been sick recently? Any pain? Rate your pain? SKIN: Endorses change in skin color ? What color is the discoloration? Any rash or itching? Any excessive sun exposure? Change in bath soap or lotion? HEENT: Eyes: Do you have any visual loss, blurred vision or double vision? Any discoloration in your eyes? Ears, Nose, Throat: Do you have any hearing loss? Discharge from your ears? Any sneezing, congestion, runny nose, drainage or sore throat? Any mouth sores? Any sore throat, dental hygiene issues, swollen lymph glands or hoarsness? CARDIOVASCULAR: Any chest pain, cyanosis, edema? Any congenital heart disease? RESPIRATORY: Do you have any SOB, cough? Do you have SOB with exercise or syncope? Do you have any pleuritic chest pain? Or hemoptysis? GASTROINTESTINAL: Endorses, 5lbs weight loss, nausea and stomach cramps . When did symptoms start? What is the location of your discomfort? Any aggravating or relieving factors? Any vomiting, diarrhea or constipation? Any change in your diet? Or consumption of mushrooms? Have you noticed any abnormal masses in your abdomen? Any appetite changes, dysphagia, indigestion or food idiosyncrasy? Any symptoms associated with abd pain such as heartburn, eructation or hematemesis? How much alcohol do you consume? Did you start having your symptoms after you started taking CoQ10? GENITOURINARY: Have you noticed any frequency in urination – without dysuria? Have you noticed any other signs such as urgency, abd pain, flank pain, blood in your urine or difficulty initiating micturition? Any history of genitourinary infections? When did you achieve night dryness? What is your menstrual cycle? Any heavy flow, pain? What symptoms are associated
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