I have done some of the paper. please address the 6 questions in different paragraphs.with referances from the resources provided.and conclusion.
Comprehensive SOAP Note
NURS 6531N- 20
Practicum Experience Assignment 3#
Patient name- BR Age- 68 Sex- Black female
Chief Complaint (CC): “I am having blurred vision and headaches and sometimes they make me nauseated”. I recently was placed on a different blood Pressure medication two weeks ago.
History of Present Illness (HPI): This is a 68yr. old black female presenting to the clinic with complaints of headaches with blurred vision and nausea for two week. Patient states she experienced low-grade fever that morning. Patient states she was placed on Lisinopril 20mg PO daily.
Medications: Zantac 75mg PO daily, Lisinopril 20mg PO daily,ASA 81 mg PO daily, Advair 50mg PRN
Allergies: NKDA.
Past Medical History (PMH): Ashma , HTN, Arthritis
Past Surgical History (PSH): Appendectomy ten years ago
Immunization History: Immunizations up-to-date to age.
Significant Family History: Both parents are no longer living and both had HTN. Patient has one younger brother with HTN.
Lifestyle: Retired and lives on Social security .
REVIEW OF SYSTEMS:
General: Alert with complaints of fatigue due to nausea
Respiratory: Denies any shortness of breath or cough
Cardiovascular/Peripheral Vascular: Denies chest pain or any other heart symptoms
Musculoskeletal: Some Joint pain in the mornings .
HEENT: Blurred vision.
Psychiatric: Anxious related to disease process
Skin: Denies any skin issues, rash or lesions
Gastrointestinal- complaints of off and on Nauesa
Hematologic: Denies bruising
Endocrine: Denies polydipsia, polyuria, polyphagia
Neuro- Denies any loss in memory, seizures.
GU- Denies difficulty or pain in urinating.
OBJECTIVE DATA
Physical Exam:
Vital signs: T 98.4 F, BP 140/101, P- 101, R- 22, SPO2 98 % room air.
General: 68-year-old female, alert oriented,
Neurological – No abnormal positioning, movements or facial asymmetry.
HEENT: PERLA, Atraumatic, normocephalic, no redness in eyes, no nose bleed, moist mucous membrane, no oral ulcers, no sore throat or tonsillitis, no ear discharge.
Neck: No carotid bruit or JVD, swollen lymph nodes noted, no stiffness, supple, symmetrical, no adenopathy, no tenderness/mass/nodules.
Chest/Lungs: Unlabored respiration, Breath sounds clear bilaterally.
Cardiovascular- Regular rate and rhythm. S1 and S2 normal. No murmur, rub, or gallop. Thorax symmetrical
Chest wall- No tenderness or deformity.
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