NR 601 MAT ADLT WEEK 2 SOAP 2

NR 601 MAT ADLT WEEK 2 SOAP 2

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NR 601 MAT ADLT WEEK 2 SOAP 2

PMH:

Chronic back pain

Hypertension

CARDIOVASCULAR:

RESPIRATORY:

GASTROINTESTINAL:  No reports anorexia, nausea, vomiting or diarrhea or abdominal pain or blood.

GENITOURINARY:  No reports of frequency, urgency, burning

NEUROLOGICAL:  No headache, dizziness, syncope, paralysis, ataxia,  Reports numbness and  tingling in the lower extremities “my feet just burn and tingle all the time and it is so much worse at night”

No change in bowel or bladder control.

MUSCULOSKELETAL:  No muscle, back pain, joint pain or stiffness.

HEMATOLOGIC:  No reported anemia, bleeding or bruising.

LYMPHATICS:  No enlarged nodes. No history of splenectomy.

PSYCHIATRIC:  No history of depression or anxiety;

ENDOCRINOLOGIC:  Diabetic current treatment includes insulin and oral hyperglycemic; currently taking L-Thyroxine

ALLERGIES:  Allergic to amoxicillin, No history of asthma, hives, eczema or rhinitis.

Physical examination:

Vital Signs

Height: 5 feet 2 inches Weight: 163 pounds BMI: 29.8   BP 110/70 T 98.0 po P 100 R 22, non-labored; Urinalysis: Protein 2+, Glucose: 4+

HEENT:tinnitus

NECK: 

LUNGS: Decreased breath sounds in bases bilaterally with rales,

HEART: Irregularly irregular rhythm; Unable to detect S3 or murmur

ABDOMEN: Normal contour;

PV: 

NEUROLOGIC: 

GENITOURINARY: 

MUSCULOSKELETAL: .

PSYCH:

SKIN