NSG 6020 Soap Note – Angina Pectoris

NSG 6020 Soap Note – Angina Pectoris or Acute MI Diagnosis

NSG 6020 Soap Note – Angina Pectoris or Acute MI Diagnosis

SOAP NOTE

Don't use plagiarized sources. Get Your Custom Essay on
NSG 6020 Soap Note – Angina Pectoris
From $8/Page
Order Essay
Name: T. H. 7/21/ Time: 9:00 am
Age: 47 Sex: Female
SUBJECTIVE
CC: 

“I’m here because my left arm feels funny and tingles all the time”.

 

HPI: 

Mrs. H. is 47 year old female patient presenting to the office today for with left arm tingling and numbness. She had a recent visit to the ER due to BLE edema. She was given Lasix and her lab work showed several electrolyte imbalances.  She states that she has also had chest pain throughout the week. Her last office visit consisted of an evaluation and lab work to evaluate her thyroid status. She denies any fever, diaphoresis, shortness of breath or chest pain.

Medications:                     

Magnesium oxide 400 mg 1 tab by mouth daily

Potassium Chloride 10 meq capsule daily

Levothyroid 125 mcg tab daily. NSG 6020 Soap Note – Angina Pectoris or Acute MI Diagnosis

Lisinopril hydrochlorothiazide 20-12.5 mg tablet daily

Lipitor 40 mg daily

Ultram 50 mg every six hours as needed for pain

PMH

Allergies:  Sulfa

Medication Intolerances:

Sulfa antibiotics

Chronic Illnesses/Major traumas

Hypothyroidism

Chronic Health Problems:

  1. Hypothyroidism (E03.9)
  2. Hyperlipidemia

Hospitalizations/Surgeries

Cholecystectomy

Tubal ligation

Left knee Arthroscopy

Other:

Immunizations: unknown

Environmental hazards: Denies any environmental hazards. Able to perform ADLs without difficulty.

Safety measures: Stated not discussed

Exercise and leisure: She gets short of breath with strenuous activities.

Sleep: Tries to get at least 6 hours of sleep every night.

Diet: Admits to unhealthy eating habits.

Family History

Did not provide information

Social History

She drinks socially. Denies smoking. Denies illicit drugs. NSG 6020 Soap Note – Angina Pectoris or Acute MI Diagnosis

ROS
General

Admits frequent fatigue. Denies fever, night sweats or recent weight gain or loss.

Cardiovascular

Occasional chest pain. No murmur, bruits, palpitations, or edema.

Skin

Skin intact. No lesions noted.  Denies any rash or itching.

Respiratory

Denies cough. Denies hemoptysis, wheezing, or exposure to TB. Admits to SOB on exertion.

Eyes

Denies complaints of blurred vision or visual disturbances reported.

Gastrointestinal

Denies abdominal pain, nausea, vomiting, dysphagia or abnormal stools.

Ears

Denies hearing loss discharge or ear pain.

Genitourinary/Gynecological

Denies any frequency, hesitancy, nocturia or urgency.

Nose/Mouth/Throat

Denies dryness, hoarseness, or mouth pain.

Musculoskeletal

Denies pain.

Breast

SBE, lumps, bumps or changes

Neurological

Denies syncope or headache, focal weakness, numbness, paresthesia’s, tremors, gait instability, falls or memory loss. NSG 6020 Soap Note – Angina Pectoris or Acute MI Diagnosis

Heme/Lymph/Endo: Denies easy bruising, bleeding, or blood clots. Denies increased hunger or thirst. Denies recent weight loss. Denise night sweats or swollen glands. Psychiatric

Denies any anxiety or suicidal ideations

OBJECTIVE
Weight 198 lbs       BMI 34.0 Temp 98.6 BP 128/72
Height 5’4” Pulse 52 Resp 16
General Appearance

This is a pleasant 47 year old Caucasian female that presents in mild distress.

Skin

No cyanosis or clubbing noted. No rashes or lesions noted.

HEENT

Head: Head is normocephalic, no tenderness during palpation.

Eyes: PERRLA (3 mm)

Ears: External auditory canals with some cerumen and fluid noted bilaterally. Tympanic membranes intact, pearly gray with light reflex noted.

Nose: Nasal mucosa moist without drainage, septum midline.

Neck: Supple. Full ROM. No lymphadenopathy; no occipital nodes. No thyromegaly or nodules or masses palpated. Oral mucosa pink and moist. Trachea midline.

Kindly for a complete and more resourceful answer.

NSG 6020 Week 5 SOAP Note Assignment

SOAP Note

Each week you are required to enter your patient encounters into CORE. Your faculty will be checking to ensure you are seeing the right number and mix of patients for a good learning experience. Beginning in Week 5, you will need to include one complete SOAP note each week through Week 9 for a total of 5 complete SOAP notes for this course using this SOAP note template. The SOAP note should be related to the content covered in this week, and the completed SOAP note should be submitted to the Submissions Area. When submitting your note, be sure to include the reference number from CORE where you entered this specific patient’s case entry. NSG 6020 Soap Note – Angina Pectoris or Acute MI Diagnosis

Submission Details:

By the due date assigned, enter your patient encounters into CORE and complete at least one SOAP note in the template provided.

Name your SOAP note document SU_NSG 6020_W5_A2_LastName_FirstInitial.doc.

Include the reference number from CORE in your document.

Submit your document to the Submissions Area by the due date assigned.

NSG 6020 Week 6 SOAP Note Assignment

SOAP Note

Each week you are required to enter your patient encounters into CORE. Your faculty will be checking to ensure you are seeing the right number and mix of patients for a good learning experience. Beginning in Week 5, you will need to include one complete SOAP note each week through Week 9 for a total of 5 complete SOAP notes for this course using this SOAP note template. The SOAP note should be related to the content covered in this week, and the completed SOAP note should be submitted to the Submission Area. When submitting your note, be sure to include the reference number from CORE where you entered this specific patient’s case entry.

Submission Details:

By the due date assigned, enter your patient encounters into CORE and complete at least one SOAP note in the template provided.

Name your SOAP note document SU_NSG 6020_W6_A4_LastName_FirstInitial.doc.

Include the reference number from CORE in your document.

Submit your document to the Submissions Area by the due date assigned.

NSG 6020 Week 6 Physical Exam Video and Write Up Assignment

Complete Health History and Physical Assessment Write-Up Presentation

This assignment consists of complete head to toe physical while being videoed. You will also need to complete a written assignment of your findings. Review the Expanded rubric to note how you will be graded on this assignment.

NSG 6020 Week 7 SOAP Note Assignment

Each week you are required to enter your patient encounters into CORE. Your faculty will be checking to ensure you are seeing the right number and mix of patients for a good learning experience. Beginning in Week 5, you will need to include one complete SOAP note each week through Week 9 for a total of 5 complete SOAP notes for this course using this SOAP note template. The SOAP note should be related to the content covered in this week, and the completed SOAP note should be submitted to the Submissions Area. When submitting your note, be sure to include the reference number from CORE where you entered this specific patient’s case entry.

Submission Details:

By the due date assigned, enter your patient encounters into CORE and complete at least one SOAP note in the template provided.

Name your SOAP note document SU_NSG 6020_W7_A3_LastName_FirstInitial.doc.

Include the reference number from CORE in your document.

Submit your document to the Submissions Area by the due date assigned.

NSG 6020 Week 8 SOAP Note Assignment

SOAP Note

Each week you are required to enter your patient encounters into CORE. Your faculty will be checking to ensure you are seeing the right number and mix of patients for a good learning experience. Beginning in Week 5, you will need to include one complete SOAP note each week through Week 9 for a total of 5 complete SOAP notes for this course using this SOAP note template. The SOAP note should be related to the content covered in this week, and the completed SOAP note should be submitted to the Submissions Area. When submitting your note, be sure to include the reference number from CORE where you entered this specific patient’s case entry.

Submission Details:

By the due date assigned, enter your patient encounters into CORE and complete at least one SOAP note in the template provided.

Name your SOAP note document SU_NSG 6020_W8_A3_LastName_FirstInitial.doc.

Include the reference number from CORE in your document.

Submit your document to the Submissions Area by the due date assigned.

NSG 6020 Week 9 SOAP Note Assignment

SOAP NOTE

Each week you are required to enter your patient encounters into CORE. Your faculty will be checking to ensure you are seeing the right number and mix of patients for a good learning experience. Beginning in Week 5, you will need to include one complete SOAP note each week through Week 9 for a total of 5 complete SOAP notes for this course using this SOAP note template. The SOAP note should be related to the content covered in this week, and the completed SOAP note should be submitted to the Submissions Area. When submitting your note, be sure to include the reference number from CORE where you entered this specific patient’s case entry.

Submission Details:

By the due date assigned enter your patient encounters into CORE and complete at least one SOAP note in the template provided.

Name your SOAP note document SU_NSG 6020_W9_A3_LastName_FirstInitial.doc.

Include the reference number from CORE in your document.

Submit your document to the Submissions Area by the due date assigned.

 

Full satisfaction or return your money back

Our experts will write you a top-quality paper and revise it an unlimited number of times until you're 100% satisfied - or offer a refund.

Check Prices
Get the best discount and better grades here
Pages (550 words)
$0.00
*Price with a welcome 15% discount applied.
Pro tip: If you want to save more money and pay the lowest price, you need to set a more extended deadline.
We know that being a student these days is hard. Because of this, our prices are some of the lowest on the market.

Instead, we offer perks, discounts, and free services to enhance your experience.
Sign up, place your order, and leave the rest to our professional paper writers in less than 2 minutes.
step 1
Upload assignment instructions
Fill out the order form and provide paper details. You can even attach screenshots or add additional instructions later. If something is not clear or missing, the writer will contact you for clarification.
How to get the most out of your experience with Toptutor4me
One writer throughout the entire course
If you like the writer, you can hire them again. Just copy & paste their ID on the order form ("Preferred Writer's ID" field). This way, your vocabulary will be uniform, and the writer will be aware of your needs.
The same paper from different writers
You can order essay or any other work from two different writers to choose the best one or give another version to a friend. This can be done through the add-on "Same paper from another writer."
Copy of sources used by the writer
Our college essay writers work with ScienceDirect and other databases. They can send you articles or materials used in PDF or through screenshots. Just tick the "Copy of sources" field on the order form.
Here is what our happy clients say about us.
Receiving customer feedback and reviews from legit students who have utilized our services is one of our favorite part of the job. We love seeing testimonials from happy students whom we have helped to succeed. Read through the below review page to see what our partners think.
Psychology
Very clear, and complete information presented. I, thank you for all of your hard work, appreciate it!
Customer 452483, August 9th, 2021
Biology (and other Life Sciences)
Power Point Presentation was great, appreciate all of your hard work. Thank you!
Customer 452483, August 9th, 2021
Nursing
Excellent job! super recommended.
Customer 452487, August 24th, 2021
English 101
Perfect! Thank you so much for all of your hard work and help! Appreciate it!!
Customer 452483, August 30th, 2021
Healthcare Writing & Communications
Perfect! Thank you so much for all of your help!
Customer 452483, October 31st, 2021
Microbiology
Thank you so much for revising this paper for me. It looks great, truly appreciate it! You're awesome :)
Customer 452483, September 14th, 2021
Nursing
Good job!! Thank you!!!
Customer 452487, September 9th, 2021
English 101
Perfect! Very informative! Appreciate all of your hard work! Thank you very much.
Customer 452483, September 22nd, 2021
Communications
Well done! I thank you very much!
Customer 452483, July 9th, 2021
Psychology
Thank you so much for all of your hard work & help! It’s perfect! Appreciate it!!
Customer 452483, September 11th, 2021
Nursing
Excellent! Thank you.
Customer 452487, October 16th, 2021
Communications
Thank you! It was great :)
Customer 452483, July 26th, 2021
11,595
Total Reviews
98%
Satsfaction rate
6 pages
Average paper length
40%
Customers referred by a friend
Enjoy the best prices and lifetime 15% discount
Use a coupon TOP15 and enjoy expert help with any task at the most affordable price.
Order Now Order in Chat