Unit 4: Cranial Nerves, Thyroid, Neck, and Regional Lymphatics Assignment 1: Comprehensive SOAP Note This Assignment will help develop skills to perform an integrated history and physical examination for individuals across the lifespan. Considerations of lifestyle practices, cultural/ethnic differences, and developmental variations will be incorporated into the plan of care. This guide will assist you to document history data, and perform a comprehensive physical exam in an organized and systematic manner.Please include a heart exam and lung exam on all clients regardless of the reason for seeking care.So, if someone presented with cough and cold symptoms, you would examine the General appearance, HEENT, Neck, Heart and Lungs for a focused/episodic exam.However, this Assignment requires assessment of .The pertinent positive findings should be relevant to the chief complaint and health history data. Please follow the guide and include all previous sections of the SOAP Note with corrections based on feedback, as well as the Objective and Plan sections. A:Biographical Data B: Source of history and reliability C:Chief Complaint D:story of Present Illness (HPI) E: Past Medical story F:Family story G:Social story (alcohol, drug, or tobacco use) H.Lifestyle Patterns I:Allergies J:Current Medications Wgt Δ; weakness; fatigue; fevers : No weight gain or losses; no weaknesses, fatigue, or fevers Positive weight gain over past 2 months with fatigue and weakness; no fevers Rash; lumps; sores; itching; dryness; color change; Δ in hair/nails Headache; head injury; dizziness or vertigo Vision Δ; eye pain, redness or swelling, corrective lenses; last eye exam; excessive tearing; double vision; blurred vision; scotoma Hearing Δ; tinnitus; earaches; infections; discharge, hearing loss, hearing aid use Colds; congestion;nasal obstruction, discharge; itching; hay fever or allergies; nosebleeds;change in sense of smell; sinus pain Bleeding gums; mouth pain, tooth ache, lesions in mouth or tongue, dentures; last dental exam; sore tongue; dry mouth; sore throats; hoarse; tonsillectomy; altered taste Lumps; enlarged or tender nodes, swollen glands; goiter; pain; neck stiffness; limitation of motion Lumps; pain; discomfort; nipple discharge, rash, surgeries, history of breast disease; performs self-breast exams and how often, last mammogram; any tenderness, lumps, swelling, or rash of axilla area Cough—productive/non-productive; hemoptysis; dyspnea; wheezing; pleuritic pains; any H/O lung disease; toxin or pollution exposure; last Chest X-RAY, TB skin test Chest pain or discomfort; palpitations; dyspnea; orthopnea; edema, cyanosis, nocturia; H/O murmurs, hypertension, anemia, or CAD Appetite Δ; jaundice; nausea/emesis; dysphagi
a; heartburn; pain; belching/flatulence; Δ in bowel habits; hematochezia; melena; hemorrhoids; constipation; diarrhea; food intolerance Frequency; nocturia; urgency; dysuria; hematuria; incontinence Use of kegal exercises after childbirth; use of birth control methods; HIV exposure; Menarche; frequency/duration of menses; dysmenorrhea; PMS symptoms: bleeding between menses or after intercourse; LMP; vaginal discharge; itching; sores; lumps Menopause; hot flashes; post-menopausal bleeding; caliber of urinary stream; hesitancy; dribbling; hernia, Sexual habits; interest; function; satisfaction; Discharge from or sores on penis; HIV exposure; testicular pain/masses; testicular exam and how often Claudication; coldness, tingling, and numbness; leg cramps; varicose veins; H/O blood clots, discoloration of hands, ulcers Muscle or joint pain or cramps; joint stiffness; H/O arthritis or Gout; limitation of movement; H/O disk disease Syncope; seizures; weakness; paralysis; stroke, numbness/tingling; tremors or tics; involuntary movements; coordination problems;memory disorder or mood change; H/O mental disorders or hallucinations Hx of anemia; easy bruising or bleeding; blood transfusions or reactions; lymph node swelling; exposure to toxic agents or radiation Heat or cold intolerance; excessive sweating; polydipsia; polyphagia; polyuria;glove or shoe size; H/O diabetes, thyroid disease; or hormone replacement; abnormal hair distribution Nervousness/anxiety; depression; memory changes; suicide attempts;H/O mental illnesses 1. 2. 3. 1. Prescriptions with dosage, route, duration, and amount prescribed and if refills provided 2. Diagnostic testing 3. Problem oriented education 4. Health Promotion/Maintenance Needs (When will you schedule a follow-up appointment and what will you address in the subsequent visit —F/U in 2 weeks; Plan to check annual labs on RTC(return to clinic). Select a Nursing Theory and apply this to your patient’s plan and evaluation (brief statement). VI.Developmental Stage:Identify the developmental state and provide rational to support acquisition of skills in the stage (brief statement). VII.Cultural Characteristics, Diversity, Sensitivity & Ethical Considerations Discuss culturally diverse considerations you identified for this patient.Cultural Diversity is a general term that can include gender, religious beliefs, culture, race, economic status, age, and etc.Discuss one ethical standard relevant to the care of this patient. Provide a brief statement sharing your thoughts about the visit and/or patient.Please share what you should have done differently. Please include a minimum of three references.The reference list must be in APA format.All sources must be within 5 years of publication.