Mental status and psychiatric reports sleep objective

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Mental Status and Psychiatric: Reports sleep disturbance/insominia. OBJECTIVE : Vital Signs: Pulse: 76 BP: 148/82 on right arm with patient sitting with large adult cuff. RR: 20 breaths per minute O2sat: 97% on room air Temp: 97.9 orally Ht: 5 ft 4 inches Wt: 210 lbs BMI: 36.0, patient is morbidly obese General Appearance statement: Patient is a 52 year old Hispanic female. Patient present with a pleasant affect and well groomed. No distress noted during this visit. Physical Exam:
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SOAP NOTE Page 5 of 8 Skin, Hair, and Nails: Skin appropriate to race and age. Skin is soft, dry, warm, without tenting. Skin is intact throughout the body. Warm and pink. No cyanosis or clubbing noted on the nail beds. Hair is black, well maintained and shiny. Capillary refill < 3sec. Head & Neck: Head normocephalic, Scalp freely movable without lesions or tenderness. Scalp is dry. Facial features and expressions symmetrical when talking; assessing CN VII. No bruit present bilaterally in temporal arteries and palpable 3+ bilaterally. No tenderness or palpable lymph nodes noted. Carotid pulse palpable 3+ bilaterally. No carotid bruit auscultated bilaterally. ROM of neck and shoulders without pain or difficult; assessed CN XI during ROM. HEENT: Pupils are 4 mm constricting to 2mm, equally round and reactive to light and accommodations. Uses corrective lenses for reading. Central visual acuity 20/20 bilaterally. Sclera white, conjunctiva pink. Red reflex present. Extra-ocular muscle function is intact (EOMI). Symmetrical corneal light reflex. Visual fields full to confrontation. Upon fundoscopic exam, disc margins sharp; no hemorrhages or exudates, no arteriolar narrowing. Ears: Pinna, tragus, and external canal non-tender. Ear canal clear and tympanic membranes (TMs) with good cone of light. Acuity good to whispered voice. Weber midline. Rinne in both ears. Nose: Nares patent bilaterally. Nasal mucosa pink, septum midline. Olfaction intact Chest and Lungs: No distress or labored breathing. No chest pain. No tenderness upon palpation. No CVA tenderness. Resonant percussion throughout. Tactile fremitus symmetrically. Auscultated clear lung sounds bilaterally. No adventitious sounds noted. Cardiovascular: S1 and S2 heard, no S3 or S4. No gallops, rubs, or murmurs. Pulses present radial 3+ and pedal 3+. Capillary refill <3 bilaterally on upper and lower extremities. No palpitations or syncope noted. Allen’s test < 3 seconds. 2+ Pitting edema bilaterally at lower extremities. Breast: Full exam deferred. No complaints of pain or swelling. Educated on self-breast examination Gastrointestinal : Abdomen soft and non-distended. Present sound in all 4 quadrants. No abdominal pulsations or bruits. Denies pain and discomfort upon palpation. No palpable masses or hepatosplenomegaly. Kidneys not felt, no flank pain or CVA tenderness.
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  • Fall '19
  • Diabetes mellitus type 2, Diabetic neuropathy, dyslipidemia

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