solved

Question
Answered step-by-step
Asked by smitchell56

Class Nurs 505- Advanced Health Assessment I need to write a soap note for a HEENT exam. The attached pdf is the example we were given.  I’m not sure what exactly is meant by the last section where they ask us to discuss nursing theory, health promotion, family ilfe diversity and evaluation. any ideas?

1 attachment
•
View all attachment
SOAP example:
Skin/Hair/Nails
SUBJECTIVE
Ms. P is a pleasant, 33-year-old, single, African American, recently unemployed computer
programmer with a chief complaint of thinning hair and diffuse itching.
History of Present Illness
: Client has noticed scalp hair thinning, and increasing pruritis without
rash in her scalp, back, arms, face, and neck over the past year. Scalp thinning pattern is reported
to be diffuse, not in patches or clumps. Denies eyebrow or eyelash thinning. No hx of thyroid
disease, and states her TSH was checked x 2 in the past year and reported normal both times.
Has not noticed any alleviating or aggravating factors for the hair thinning.
Itching is worse in heat (weather, household temperature, or exercise). Partial, temporary relief
with cool shower, with gradual resolution over ~1 hr. General body sx occur ~ every two or three
months, and scalp itching flares after a perm. Client states that the scalp itching interferes with
sleep the day of her perm. No personal or family hx of asthma or eczema. Reports mother with
significantly thinned scalp hair starting around age 40.
PMHx
:
“Healthy”. No medical problems known. No surgeries.
Medications
:
None
Allergies
:
NKDA
OBJECTIVE
PE:
General:
142#
BP 124/80 p 80
T 98.1
HEENT
:
Head
:
Comment on symmetry and any tenderness
Eyes
:
Conjunctiva:
Sclera: Pupils: EOMs:
Ophthalmoscope:
Eyelids:
Eyebrows:
Ears
:
TM’s:
Canals:
Weber:
Rinne:
Nose
:
Septum:
Nasal mucosa:
Maxillary and frontal sinuses:
Throat/Neck
:
Oral mucosa:
Uvula:
Tonsils:
Gums:
Tongue:
Trachea:
Neck:
Comment on lymphadenopathy presence/absence and what nodes are enlarged if
applicable.
Thyroid
:
Cardiac
:
Basic cardiac exam:
Comment on rate/rhythm, presence/absence of murmur(s)
2 pages
SCIENCE
HEALTH SCIENCE
NURSING