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NR 509 Week 5 Abdominal Pain SOAP Note

NR 509 Week 5 Abdominal Pain SOAP NoteNR 509 Week 5 Abdominal Pain SOAP NoteThe content covered so far includes the following:Subjective, objective, assessment, and plan (SOAP) notes; physical examsS; history taking; head, eyes, ears, nose, and throat (HEENT); respiratory; and cardiovascular systems, in addition to the gastrointestinal (GI) system content that we are covering this week..This GI system content this week will focus on the abdomen. The abdomen houses important organs such as the liver, spleen, intestines, pancreas, and the stomach. There are millions of office visits that abdominal complaints are responsible for each year. This week will look at common GI complaints related to the history, assessment findings, diagnostic testing, and differential diagnoses for the chief complaint.NR 509 Week 5 Abdominal Pain SOAP NotePLEASE USE THE TEMPLATE PROVIDED IN THE ATTACHMENT. THE SOAP NOTE HAS TO BE DONE UNDER *ONE* OF THE GASTROINTESTINAL DISEASES, FOR EXAMPLE, GERD, PEPTIC ULCER, ETC.. TEMPLATE IS ATTACHED TO THIS POST.ORDER A PLAGIARISM-FREE PAPER HERESOAP NOTEName: Date: Time: Age: Sex: SUBJECTIVE CC:Reason given by the patient for seeking medical care “in quotes”HPI:Describe the course of the patient’s illness, including when it began, character of symptoms, locationwhere the symptoms began, aggravating or alleviating factors; pertinent positives and negatives, otherrelated diseases, past illnesses, surgeries or past diagnostic testing related to present illness.Medications: (list with reason for med )PMHAllergies:NR 509 Week 5 Abdominal Pain SOAP NoteMedication Intolerances:Chronic Illnesses/Major traumasHospitalizations/Surgeries“Have you every been told that you have: Diabetes, HTN, peptic ulcer disease, asthma, lung disease, heartdisease, cancer, TB, thyroid problems or kidney disease or psychiatric diagnosis.”Family HistoryDoes your mother, father or siblings have any medical or psychiatric illnesses? Anyone diagnosed with:lung disease, heart disease, htn, cancer, TB, DM, or kidney disease.Social HistoryEducation level, occupational history, current living situation/partner/marital status, substance use/abuse,ETOH, tobacco, marijuana. Safety statusROS GeneralWeight change, fatigue, fever, chills, night sweats,energy levelCardiovascularChest pain, palpitations, PND, orthopnea, edemaSkinDelayed healing, rashes, bruising, bleeding or skindiscolorations, any changes in lesions or molesRespiratoryCough, wheezing, hemoptysis, dyspnea, pneumoniahx, TBEyesCorrective lenses, blurring, visual changes of anykindGastrointestinalAbdominal pain, N/V/D, constipation, hepatitis,hemorrhoids, eating disorders, ulcers, black tarrystoolsEarsEar pain, hearing loss, ringing in ears, dischargeGenitourinary/GynecologicalUrgency, frequency burning, change in color ofurine.NR 509 Week 5 Abdominal Pain SOAP NoteContraception, sexual activity, STDSFe: last pap, breast, mammo, menstrualcomplaints, vaginal discharge, pregnancy hxMale: prostate, PSA, urinary complaintsNose/Mouth/ThroatSinus problems, dysphagia, nose bleeds ordischarge, dental disease, hoarseness, throat painMusculoskeletalBack pain, joint swelling, stiffness or pain, fracturehx, osteoporosisBreastSBE, lumps, bumps or changesNeurologicalSyncope, seizures, transient paralysis, weakness,paresthesias, black out spells Heme/Lymph/EndoHIV status, bruising, blood transfusion hx, nightsweats, swollen glands, increase thirst, increasehunger, cold or heat intolerancePsychiatricDepression, anxiety, sleeping difficulties, suicidalideation/attempts, previous dxOBJECTIVEWeight BMI Temp BP Height Pulse Resp General AppearanceHealthy appearing adult female in no acute distress. Alert and oriented; answers questions appropriately.NR 509 Week 5 Abdominal Pain SOAP NoteSlightly somber affect at first, then brighter later. SkinSkin is brown, warm, dry, clean and intact. No rashes or lesions noted. HEENTHead is normocephalic, atraumatic and without lesions; hair evenly distributed. Eyes: PERRLA. EOMsintact. No conjunctival or scleral injection. Ears: Canals patent. Bilateral TMs pearly grey with positivelight 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. CardiovascularS1, S2 with regular rate and rhythm. No extra sounds, clicks, rubs or murmurs. Capillary refill 2 seconds.Pulses 3+ throughout. No edema. RespiratorySymmetric chest wall. Respirations regular and easy; lungs clear to auscultation bilaterally. GastrointestinalAbdomen obese; BS active in all 4 quadrants. Abdomen soft, non-tender. No hepatosplenomegaly. BreastBreast is free from masses or tenderness, no discharge, no dimpling, wrinkling or discoloration of the skin. GenitourinaryBladder is non-distended; no CVA tenderness. External genitalia reveals coarse pubic hair in normaldistribution; 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 pinkand 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.NR 509 Week 5 Abdominal Pain SOAP Note(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 issmooth, non-tender and free from nodules, is of normal size, sphincter tone is firm). MusculoskeletalFull ROM seen in all 4 extremities as patient moved about the exam room. NeurologicalSpeech clear. Good tone. Posture erect. Balance stable; gait normal. PsychiatricAlert and oriented. Dressed in clean slacks, shirt and coat. Maintains eye contact. Speech is soft, thoughclear and of normal rate and cadence; answers questions appropriately.NR 509 Week 5 Abdominal Pain SOAP NoteLab TestsUrinalysis – pendingUrine culture – pendingWet prep – pendingSpecial TestsDiagnosisDifferential Diagnoseso 1- o 2- o 3-DiagnosisoPlan/Therapeuticso Plan: Further testing Medication Education Non-medication treatmentsEvaluation of patient encounterNR 509 Week 5 Abdominal Pain SOAP Note

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