Week six focused SOAP note NURS 6531   NURS 6531 Week six focused SOAP note – NURS 6531 Week 6 SOAP note Week six focused SOAP note NURS 6531   NURS 6531 Week six focused SOAP note – NURS 6531 Week 6

************ * **************** *** ******* **** ******** ************************************************* *********** *** *** ****************** ******* ** * *** year-old Caucasian ****** who *** *** abdominal **** frequency ******* ******* *** nausea/indigestion ***** ******* *** days ago **** ** highest ** 5/10 however is ********* ** **** *** ********* **** ********* and ******** Some ******** ** felt in ******* **** ******** ** ********* *** ******** ******** with ******** is ******** ******** by TylenolAbdomen is * pressure **** **** ** lower region *** ** exacerbated **** ****** ** comes and **** *** ************ ****** **** bloating Denies ******** diarrhea ********* ********** ***** ** ******** ** illnessCurrent ************ ******* **** po **** ****************** 2 tablets ** needed every * hours *** ************** *********** itching/hivesPMH: **** ****** ******** **** *** **** **** *************** Mild ******************* alive; HTN Father ****** no *********** ******* kidney ******** ****** ********* **** patient SH: ******** ******* ***** quit 1986 ******* lives **** ******* ** ******************* No ****** loss ***** ****** ******** ** fatigueHEENT: ***** ** ****** loss ******* ****** ****** ****** or yellow ******* Sclera *** *********** negative for ******* ** swelling **** **** ******* ** hearing **** ******** ********** ***** **** or **** *********** ** rash ** ********************** ** chest pain ***** pressure ** ***** ********** ** ************ ** ***************** ** ********* ** breath denies ******** ** ********************** No ******** moderate ****** **** ************ indigestion ** ******** ** ******** Some ********* **** *** ******** *** ***** days *** ** blood ** ****** in ***** Bloating ************************ ** ********* ** odor **** **** ********* burning ******* and frequency Left ****** **** *** ** ********************* ** ******** ** dizziness syncope ********* ****** ******** ** ******** ** *** extremities ** ****** ** ***** ** ******* *********************** ** muscle back pain ***** **** ** stiffnessLYMPHATICS: ** enlarged ***** ** ******* ** ********************* ** history of ****** ** eczema   OVS: BP ******* P 74; R 16; * **** ** 99% Wt135lbs6136 *** Ht67 ****** ******************** *** ******** No ******** ******** Not *** ************************ Heart ******* S1S2 no ******************************* ***** *** ***** ** auscultation *** percussion bilaterally No ************************ *********** ********* ** ***** *********** during ******** **************** ****** non-tender ** ******************* ******* ** ***** ** ******** to ****** **** *** ******* ********* ******* ************ ******* normal **** *** *** no ************* ****** Eye ****** and eyelids ************ ****** *** *********** non-reddened no drainage or ********* tearing ***** *** ****** clear ** ****** *********** **** ****** ***** ************* ** redness or ******** ** turbinate ** ***** ******** ** **** **** *********** ** ************ ** rashes or redness ** excessive dryness or **** ****************** ***** *** oriented ******* ********* *********************** ** abnormal ******** **** **** Tender ** ********* ********* ***** ********* **** ****** ** ***** ********* No ******** ***** sounds ****** ** No aortic abnormalities splenomegaly ** rebound ********** ** ******** **** *** ******** ******** ************* ** CVA ********** **** palpationDiagnostic ******** *** ** ***** ******* analysis negative Culture ********* however returned as ** ***** **** **** *** ***** floraFurther testing to ******** ***** ******* ********* * *** *** and **** **** ** ********* to rule out cardiac involvement ******** stool for occult ***** ***** ******* *** ******** blood ************* Diagnosis/Presumptive ********** Constipation ******* presented ******* has ****** indigestion ***** ********* **** *** urinary ******** which could ** ******* ** this ** ***** ** * ******** ** *** ********** and ******* **** ***** **** ********* with ******** ******** of ******* ***** ********* ******* **** can ** **** ** ***** ** ************ ** *** colon ** ***** to the ******* ***** *** ******** with ******** ************ ******* *** ***** ******** *** **** ** common (Buttaro et ****** pp646) This *** ** ******* **** comfort measures **** fluids *** OTC *********** to ***** ******* such as * ***** ******************** Diagnosis:1) Diverticulitis: *** ******* ****** ** ********** ** **** **** ** *** ******** *** often ** ******* and ***** *** ********* miss *** symptoms if **** *** having ******* tract ********** or ******** ** ** *** ***** *** **** ***** culture returns as negative *** patient *** and *** ******* with constipation **** * steady ****** abdominal **** ** the **** ***** quadrant ** well ** ******* ***** ********** and ****** ******* et ** ***** ** **** **** is ********* * *********** and should ** ******* assessed2Gerd: **** can ******* *** symptoms ** *********** *** nausea Being ** **** ** * ****** ******** ********* *** the ****** ******* includes *********** ** ********* **** ** ******** *** **** ******* I ***** **** ** ***** *** ***** signs *** symptoms as well ** * hemoccult ******* ** ** ***** pp672) She ** **** ****** ** SSRI Celexa *** **** is ** ********* risk for developing **** ****** (Drugscom2017)3) ******* ***** ********** ******* may **** ** infection ***** may ***** show ** ** ******* ** ** ********* ** send ***** *** ******* to ******* ******* * ********* Patient *** a ******* ** ***** ********** ***** presented **** similar symptoms **** should not be ***** out ***** ******* ********** checking *** **** ***** there **** **** *** ***** ********************** ******* ** seen ** ** for *** *** ***** ****** rule *** ******* ******* ******** **** ** *** ******* *** **** ******* if ******** is ***** Patient ** ****** up with *** ** three **** ********* ******* ******** ******* ****** ****** ** ****** care/ ** ** ******** persist ****** ** *** ******** ***** **** ****** *** rest *** ******* symptoms and *** ******** **** Tylenol *** *** ** ****** for pain ******* *** follow bland **** such ** ******* **** ****** toast *** ****** ** ******** may ** **** ** reduce *********** ***** ******** or ******** ** ***** ************************ * **** **** ******* ** **** *********** history ** ***** a ***** *** ******** seriously *** **** * previous ********* **** ****** be considered *** ***** *** prior ** final ********* *** ******** ******* ** * *** ******* * **** **** ** is ****** ********* to ******** that *** complaints of ****** *** *********** ****** not ** ***** *** as being ******* or *********** ******* **** ****** ** ******** to *** ******* *** ***** *** with ******* ******* ** discussed ********** ** ******* ******* something **** ******* ***** ** this **** * did *** **** that ***** ***** ** **** have Diverticulitis and **** ** *** to ***** **** *** ******* symptoms and ********** ********* ** ***** Buttaro it ** important ** ******** a **** assessment ********* *** cva tenderness abdominal ********** ********** ***** sounds *** ***** ********** ******** ** ****** **** you *** not ******* anything ******** ********* ***************************************************************** T * ********* * Polgar Bailey * ***** Sandberg-Cook * ****** ******* ***** * ************* practice (5th ed) ** ***** MO: **************** **** *********** ******** * ************** ************************************************* Education Inc (Executive Producer) ******* **** ****** ****** abdominal ******** Baltimore *** ******