HEARING LOSS / SOAP NOTE
SOAP NOTE
ETOH, tobacco, marijuana. Safety status
|
|
ROS | |
General
Weight change, fatigue, fever, chills, night sweats, energy level
|
Cardiovascular
Chest pain, palpitations, PND, orthopnea, edema
|
Skin
Delayed healing, rashes, bruising, bleeding or skin discolorations, any changes in lesions or moles
|
Respiratory
Cough, wheezing, hemoptysis, dyspnea, pneumonia hx, TB
|
Eyes
Corrective lenses, blurring, visual changes of any kind
|
Gastrointestinal
Abdominal pain, N/V/D, constipation, hepatitis, hemorrhoids, eating disorders, ulcers, black tarry stools
|
Ears
Ear pain, hearing loss, ringing in ears, discharge
|
Genitourinary/Gynecological
Urgency, frequency burning, change in color of urine. Contraception, sexual activity, STDS Fe: last pap, breast, mammo, menstrual complaints, vaginal discharge, pregnancy hx Male: prostate, PSA, urinary complaints
|
Nose/Mouth/Throat
Sinus problems, dysphagia, nose bleeds or discharge, dental disease, hoarseness, throat pain
|
Musculoskeletal
Back pain, joint swelling, stiffness or pain, fracture hx, osteoporosis |
Breast
SBE, lumps, bumps or changes |
Neurological
Syncope, seizures, transient paralysis, weakness, paresthesias, black out spells |
Heme/Lymph/Endo
HIV status, bruising, blood transfusion hx, night sweats, swollen glands, increase thirst, increase hunger, cold or heat intolerance |
Psychiatric
Depression, anxiety, sleeping difficulties, suicidal ideation/attempts, previous dx |
OBJECTIVE |
Weight BMI | Temp | BP |
Height | Pulse | Resp |
General Appearance Healthy appearing adult female in no acute distress. Alert and oriented; answers questions appropriately. Slightly somber affect at first, then brighter later. | ||
Skin
Skin is brown, warm, dry, clean and intact. No rashes or lesions noted. |
||
HEENT
Head is normocephalic, atraumatic and without lesions; hair evenly distributed. Eyes: PERRLA. EOMs intact. No conjunctival or scleral injection. Ears: Canals patent. Bilateral TMs pearly grey with positive light reflex; landmarks easily visualized. Nose: Nasal mucosa pink; normal turbinates. No septal deviation. Neck: Supple. Full ROM; no cervical lymphadenopathy; no occipital nodes. No thyromegaly or nodules. Oral mucosa pink and moist. Pharynx is nonerythematous and without exudate. Teeth are in good repair. |
||
Cardiovascular S1, S2 with regular rate and rhythm. No extra sounds, clicks, rubs or murmurs. Capillary refill 2 seconds. Pulses 3+ throughout. No edema. | ||
Respiratory
Symmetric chest wall. Respirations regular and easy; lungs clear to auscultation bilaterally. |
||
Gastrointestinal
Abdomen obese; BS active in all 4 quadrants. Abdomen soft, non-tender. No hepatosplenomegaly. |
||
Breast
Breast is free from masses or tenderness, no discharge, no dimpling, wrinkling or discoloration of the skin. |
||
Genitourinary
Bladder is non-distended; no CVA tenderness. External genitalia reveals coarse pubic hair in normal distribution; skin color is consistent with general pigmentation. No vulvar lesions noted. Well estrogenized. A small speculum was inserted; vaginal walls are pink and well rugated; no lesions noted. Cervix is pink and nulliparous. Scant clear to cloudy drainage present. On bimanual exam, cervix is firm. No CMT. Uterus is antevert and positioned behind a slightly distended bladder; no fullness, masses, or tenderness. No adnexal masses or tenderness. Ovaries are non-palpable. (Male: both testes palpable, no masses or lesions, no hernia, no uretheral discharge. ) (Rectal as appropriate: no evidence of hemorrhoids, fissures, bleeding or masses—Males: prostrate is smooth, non-tender and free from nodules, is of normal size, sphincter tone is firm). |
||
Musculoskeletal
Full ROM seen in all 4 extremities as patient moved about the exam room. |
||
Neurological
Speech clear. Good tone. Posture erect. Balance stable; gait normal. |
||
Psychiatric
Alert and oriented. Dressed in clean slacks, shirt and coat. Maintains eye contact. Speech is soft, though clear and of normal rate and cadence; answers questions appropriately. |
||
Lab Tests
Urinalysis – pending Urine culture – pending Wet prep – pending
|
||
Special Tests
|
||
Diagnosis | ||
Differential Diagnoses
o 1- o 2- o 3- Diagnosis o
|
||
Plan/Therapeutics | ||
o Plan:
· Further testing · Medication · Education · Non-medication treatments
|
||
Evaluation of patient encounter |
Needs help with similar assignment?
We are available 24x7 to deliver the best services and assignment ready within 3-4 hours? Order a custom-written, plagiarism-free paper
![](https://powerpointpresentationhelp.com/wp-content/uploads/2022/03/WhatsApp_icon.png)
![](https://powerpointpresentationhelp.com/wp-content/uploads/2022/03/205-2057855_essay-icon.png)