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NURS 5220 / NURS5220 Module 4 Assignment GRADED A
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NURS 5220 / NURS5220 Module 4 Assignment GRADED A / NURS 5220 / NURS5220 Module 4 Assignment GRADED A
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SOAP Note FormFamily Hx:
S/ Identifying Information: (initials, age/DOB, gender, reliability)
K.U. Not obtained. I would like to
85-year-old collect the flowing family history:
Female
Reliable historian family genetic history
and family history of hearing loss.
Personal/Social Hx:
Chief Complaint/RFE: K.U.’s husband thinks he has to
K.U. complains of decreased hearing on the right side. “repeat himself too many times”
Visit prompted by the observation of her husband when he talks to the patient and
regarding her trouble hearing over the past “couple of suggests she gets her hearing
months”. She reports that sounds on the right are checked.
somewhat hollow, "like an international phone call."
Cotton swab used by the patient in an attempt to clean The patient reported that her
out ear canals husband and friends need to
“repeat themselves”, but not shout
to her.
K.U. has no trouble hearing before
this.
Hx Present Illness: (7 Variables but do not list as such)
K.U. is an 85-year-old female. She came to the clinic with chief complaints of decreased
hearing on the right side. The patient reported that her husband has been “pestering her about
it for about 2 months”. K.U. has never had any trouble before then. K.U. states "Everything
sounds funny. I can hear noises, but speech isn't clear. It's worse on my right side." She
reports that the most trouble of hearing when she is “in the dining hall in the evening”. She
reports that sounds on the right are somewhat hollow, "as an international phone call." She
reports nobody shouted at her but her husband and best friend have to "repeat themselves".
She did not have air travel recently. She found herself watching people's lips when they talk.
In noisy restaurants, she sometimes just "don't listen to the conversation going on around
me." Cotton swab used by the patient in an attempt to clean out ear canals.
CURRENT HEALTH
Medications: Not obtained. I will ask the following questions:
Do you have any over-the-counter medicines or prescriptions since your last visit?
Allergies: Not obtained. I will ask the following questions:
Do you have any new allergies since your last visit?
Last PE & Screenings: Not obtained. I will ask the following questions:
When is your last physical exam?
Do you have any problems with your last physical exam?
Does any of your family members have any illnesses?
Immunization Status: Not obtained. I will ask the following questions:
Do you have any concerns about your immunization shots?
LMP & Birth Control (if applicable) Not applicable
, PMH
Illnesses & Trauma: Not obtained. I will ask the following questions:
Do you have any trauma before? When? How were you treated?
Do you have any illness history? When? How were you treated?
Hospitalizations/Surgeries: Not obtained. I will ask the following questions:
Do you have any surgery before? When?
Do you have any hospitalizations before? When? How many days?
OB Hx/Sexual Hx: Not obtained. I will ask the following questions:
How many children do you have?
Have you ever been diagnosed with a sexually transmitted infection? When? How were you
treated?
Emotional/Psy Hx: Not obtained. I will ask the following questions:
Do you feel stressed? How often?
Do you feel alone? How often?
How is your family relationship?
REVIEW OF SYSTEMS
General I will ask the following questions:
Do you have any concerns today?
Nutrition Not obtained. I will ask the following questions:
Do you have any concerns about nutrition for senior people?
Skin/Hair/Nails Not obtained. I will ask the following questions:
Do you have any concerns about your skin/hair/nails?
Are you bothered by itching?
HEENT K.U. complains of decreased hearing on the right side.
How long has the hearing problem been?
Do you notice any infection in your ears besides hearing loss?
Do you notice any headaches?
Does any of your family members have a hearing problem?
Do you have a middle ear infection before? When? How were you treated?
Do you notice any drainage of fluid from your ears?
Is there any pain in your ears?
Breasts Not obtained. I will ask the following questions:
Do you feel any bumps in your breast?
Respiratory Not obtained. I will ask the following questions:
Do you have any trouble breathing?
Do you cough up any mucus?
Do you notice if you get tired more often?
CV/peripheral vascular Not obtained. I will ask the following questions:
Do you notice any swelling?
GI Not obtained. I will ask the following questions:
Do you have any diarrhea?
Do you have any vomiting?
GU Not obtained. I will ask the following questions:
Do you notice peeing more often or less?
Do you notice any change in the color of your urine?
MSK Not obtained. I will ask the following questions:
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