HEENT: Conjunctiva normal - Ears: Auditory canals normal/TM normal on R side/TM normal on L side/R TM bulging and erythematous/L TM bulging and …inspection than from any of the other methods of examination. Sequence of Examination Skill, tact and patience are required to gather an optimal amount of information when examining a child. There is no routine one can use and each examination should be individualized. Ham it up and regress. Get down to the child's level and try to gain his trust.SOAP note chief complaint: sore throat subjective data female presented with complaint of sore throat and described the pain as broken attempt to measure the ... SOAP Heent - SOAP note. SOAP note. Course. Nursing Concepts and Interventions - Care for the Older Adult 1 (N3700) 36 Documents. ... Adult Exam 1 SG NURS 3700 Exam 1; 1 pt report …Heent SOAP Note EXAMPLE. This is a HEENT (Head Eyes Ear Nose Throat) Soap note example........... Course. Advanced health Assessment (NU 650) 42Documents. Students …Heent SOAP notes. Shadow Health-HEENT. Course. Advanced Health Assessment (NGR 6002) 12 Documents. Students shared 12 documents in this course. University ... Ecp 6705 PS2 - 2018 - Required class notes ; JPA Exam 3 PDF (Crow) PCC Exam 4 - Exam study guide; Preview text. HEENT (Part 2 of 2)Advanced Health Assessment - Fall 2022, NGR …Heent EXAM; MSN 572-Cardiovascular SOAP Note; Health History Worksheet SOAP week 4 copy copy; Abdominal exam; SOAP note Heent; Preview text. Objective: Body System Video and Exam Write Up Abdomen MSN572 Sect10 Advanced Health and Physical Assessment Across the Lifespan A 03/14/ SUBJECTIVE:Lips dry, symmetrical, no lesions. Teeth in good repair, gingiva pink. Buccal mucosa pink, no lesions. Tongue moist, midline Hard and soft palate intact. Stenson's And Wharton's ducts intact. Uvula midline, rises equally with phonation. Pharynx pink. Study with Quizlet and memorize flashcards containing terms like Head, Neck, Eyes and more.Apr 12, 2010 · ENT Exam. approximately 217 views in the last month. ENT: Ear canals and tympanic membranes are clear, and hearing is grossly intact. Nose reveals no obstruction or discharge. Oropharynx reveals no inflammation, swelling, exudate or lesion. Lips, teeth and gums are in good general condition. Short Version Long Version. Calculate The Result! Document your impression of the diagnosis (or differential diagnosis): “Impression: community-acquired pneumonia”. If the diagnosis is already known and the findings of your assessment remain in keeping with that diagnosis, you can comment on whether the patient is clinically improving or deteriorating: “On day 3 of treatment for ... HEENT SOAP Note #1. Course. Advanced Practice care of Adults (NURS 6531) ... behind the tympanic membrane upon physical exam that was causing the bulging of the 1. Amoxicillin 200 mg per 5 mL 1 teaspoon b.i.d. x10 days. 2. Dad will alternate with Tylenol and ibuprofen throughout the day to keep the fever down, and hopefully, this will help her to take in some solid food. 3. The patient will follow up here in two weeks to ensure resolution of the ear infection, or sooner if any of her symptoms persist ...Comprehensive SOAP Note. Barbra Scheirer Regis College NU 650 Advanced Health Assessment Professor T. Hewitt December 5, 2021. Comprehensive SOAP Note Patient name: F. Race/Ethnicity: White DOB: 7/15/ Age: 31 Y Female Marital Status: Married SUBJECTIVE Chief Complaint (CC): "I have pain in my stomach for a couple days” …MSN 572 - Week 4 - HEENT SOAP Note.docx. United States University. NURSING MSN572. Week 3 iHuman Amanda Wheaton case.docx. Chamberlain College of Nursing. NR NR509. 2 Gastrointestinal SOAP.docx. ... Left fundoscopic exam reveals sharp disc margins, no hemorrhages. Right fundoscopic exam reveals mild retinopathic changes. …HEENT: Head: Normocephalic, atraumatic, no visible or palpable masses, depressions, or scaring. Eyes: Visual acuity intact, conjunctiva clear, sclera non-icteric, EOM intact, PERRL, fundi have normal optic discs and vessels, no exudates or hemorrhages Ears: EACs clear, TMs translucent & mobile, ossicles nl appearance, hearing intact.Name: Danny Rivera Section: Week 5 - Focused Exam: Cough Week 5 Shadow Health Digital Clinical Experience Focused Exam: Cough Documentation SUBJECTIVE DATA: Chief Complaint (CC): Reports cough, runny nose, sore throat, and right ear pain.History of Present Illness (HPI): Reports cough started five days ago with coughing every few …SOAP / Chart / Progress Notes. Sample Name: Allergic Rhinitis. Description: A 23-year-old white female presents with complaint of allergies. (Medical Transcription Sample Report) SUBJECTIVE: This 23-year-old white female presents with complaint of allergies. She used to have allergies when she lived in Seattle but she thinks they are worse here.Tina Jones SOAP note 1 documentation of history and physical exam patient name (initials only) :_tj__ dob: date examined: chief complaint (reason for the visit ... breast lumps, (-) breast pain, (-) nipple changes/discharge, (-) family history. Last breast exam 4 years ago, reports self-exams at home. Cardiovascularhypertension, cyanosis ...Physical Exam: Vital signs: 37, 120/76, 100, 28, 96% on RA, 4’2”, 90 lbs., BMI General: This is a well-developed, well nourished 8 year old Puerto Rican boy who is alert and cooperative. He is a good historian and answers all health questions appropriately. He coughs every few minutes but is no distress. HEENT: Normocephalic, face ...View SICK SOAP NOTE TEMPLATE.docx from NURSING MSN 572 at United States University. The ROS and physical exam in your document should be written up as they would be for a problem focused visit. ... The HEENT part of the physical exam write up should be a comprehensive write up, including everything you assessed in your …Although there's no tax credit for taking the CFA exam, you may be able to deduct your exam expenses. To become a Chartered Financial Analyst -- CFA, for short -- you must first pa...View HEENT soap note.docx from NURSING MSN 572 at United States University. 1 HEENT Soap Note RN, BSN United States University MSN 572- Advanced Health and Physical Assessment Across the Lifespan Dr. AI Homework Help. Expert Help. Study Resources. ... or weight loss EYES: denies blurred vision, redness, or drainage Last eye …The HEENT Assessment is a comprehensive examination of a patient's head, covering not just the head but also the eyes, ears, nose, throat, and neck. This assessment allows healthcare professionals to thoroughly assess a patient's overall health when it comes to the parts of their head and identify any abnormalities that need to be addressed.In a complete medical examination, a doctor takes a patient’s health history, checks his vital signs, heart and lungs and performs a physical exam of the body from the head to the ...View WEEK-4 HEENT Soap Note.docx from MSN 572 at United States University. 1 HEENT Soap Note MSN 572- Advance Health and Physical Assessment Across the Lifespan March 28th, ... BMI: 24.4 PHYSICAL EXAM General Survey: Has throat pain for last 3 days, no difficulty in eating, as per patient.SOAP note NSG 500 Heent - Discussion post for soap note for shadow health patient Tina Jones. Advanced Health Assessment. Assignments. 84% (19) 2. TJ Heent Soap note - Shadow Health Soap Note. ... EXAM 2 - Study guide; TJ Heent Soap note - Shadow Health Soap Note; SOAP IX Neurological (3)Aug 23, 2019 · PRIMARY CARE NEW PATIENT HISTORY AND PHYSICAL. approximately 21 views in the last month. -General: Denies wt. changes, fever/chills, fatigue. sore throat/hoarseness or hearing problems. -CV: Denies chest pain, dyspnea, palpitations, edema. For instance, if you are used to documenting as one unit your findings for “HEENT” or even “HEENTN,” including the neck as well as head, eyes, ears, nose and throat, note that you are in ...Keep everyone in the loop by documenting exam findings and your next steps with the patient. It’s important to note that, well, in real-life documenting a physical exam doesn’t always happen exactly as you learned in school. Under pressure to be efficient, most providers abbreviate physical exam documentation to just the necessities.ROS: - CONSTITUTIONAL: Denies weight loss, fever and chills. - HEENT: Denies changes in vision and hearing. RESPIRATORY: Denies SOB and cough. - CV: Denies palpitations and CP. - GI: Denies abdominal pain, nausea, vomiting and diarrhea. - GU: Denies dysuria and urinary frequency. - MSK: Denies myalgia and joint pain.SOAP Note: Infant Well Visit United States University FNP: 594 Primary Health of Acute Clients/Families Across the Lifespan- ... Baby E is a Caucasian male who presents to the clinic with his mother and father today for his first newborn exam. His parents are reliable historians. DOB: 1/21/2022, ... -HEENT: denies any nasal or eye …SOAP / Chart / Progress Notes. Sample Name: Allergic Rhinitis. Description: A 23-year-old white female presents with complaint of allergies. (Medical Transcription Sample Report) SUBJECTIVE: This 23-year-old white female presents with complaint of allergies. She used to have allergies when she lived in Seattle but she thinks they are worse here.View SOAP Note #1 Tina Jones HEENT.docx from NURS 612 at Maryville University. S.O.A.P. Note Template CASE ID# _ History of Present Illness ComplaintChief …Intraoral examination reveals moist mucous membranes. There is fractured first tooth with obvious dental tenderness. No surrounding gingival erythema or fluctuance. HEENT medical transcription words and phrases - collection of transcribed samples of HEENT exam found within the physical exam section of medical reports.Sample Normal Exam Documentation. Documenting a normal exam of the head, eyes, ears, nose and throat should look something along the lines of the following: Head – The …ENT Exam. approximately 217 views in the last month. ENT: Ear canals and tympanic membranes are clear, and hearing is grossly intact. Nose reveals no obstruction or discharge. Oropharynx reveals no inflammation, swelling, exudate or lesion. Lips, teeth and gums are in good general condition. Short Version Long Version. Calculate The Result!SOAP note chief complaint: sore throat subjective data female presented with complaint of sore throat and described the pain as broken attempt to measure the ... SOAP Heent - SOAP note. SOAP note. Course. Nursing Concepts and Interventions - Care for the Older Adult 1 (N3700) 36 Documents. ... Adult Exam 1 SG NURS 3700 Exam 1; 1 pt report …1 Week 4: Assignment - Body System Exam Video and Write Up with Full SOAP note for HEENT System A - DUPI - 08-30-22 - Sect2-Advanced Health and Physical Assessment across The Lifespan United States University September 22nd' 2022 2 SOAP NOTE Date of Pati ... MSN 572 SOAP note HEENT 1 Running Head: SOAP NOTE 2 Subjective ID: Mr. …How is a non-soap bar different from soap? Find out how a non-soap bar is different from soap at HowStuffWorks. Advertisement Washing the grit and grime of the day away is a simple...ROS: - CONSTITUTIONAL: Denies weight loss, fever and chills. - HEENT: Denies changes in vision and hearing. RESPIRATORY: Denies SOB and cough. - CV: Denies palpitations and CP. - GI: Denies abdominal pain, nausea, vomiting and diarrhea. - GU: Denies dysuria and urinary frequency. - MSK: Denies myalgia and joint pain.GENERAL APPEARANCE: Well developed, well nourished, alert and cooperative, and appears to be in no acute distress. HEAD: normocephalic. EYES: PERRL, EOMI. Fundi normal, vision is grossly intact. EARS: External auditory canals and tympanic membranes clear, hearing grossly intact. NOSE: No nasal discharge. THROAT: Oral cavity and pharynx normal.Apr 12, 2010 · ENT Exam. approximately 217 views in the last month. ENT: Ear canals and tympanic membranes are clear, and hearing is grossly intact. Nose reveals no obstruction or discharge. Oropharynx reveals no inflammation, swelling, exudate or lesion. Lips, teeth and gums are in good general condition. Short Version Long Version. Calculate The Result! Diagnosis: M77.12. Lateral Epicondylitis, left elbow. CR is a 54-year-old Caucasian female who presents with pain in her left elbow (dominant hand) with wrist flexion and lateral rotation. She reports worsening pain with any activity that requires these motions and displays a positive Cozen sign on physical exam. She is a retired accountant which … heent: Head: Normocephalic, atraumatic, no visible or palpable masses, depressions, or scaring. Eyes: Visual acuity intact, conjunctiva clear, sclera non-icteric, EOM intact, PERRL, fundi Comprehensive SOAP Note. Barbra Scheirer Regis College NU 650 Advanced Health Assessment Professor T. Hewitt December 5, 2021. Comprehensive SOAP Note Patient name: F. Race/Ethnicity: White DOB: 7/15/ Age: 31 Y Female Marital Status: Married SUBJECTIVE Chief Complaint (CC): "I have pain in my stomach for a couple days” …Using the information from your HEENT examination of Tina Jones in Shadow Health, write a SOAP note and copy it into the Discussion for Module IV.Your response discussion should be a review of one other student's SOAP note, commenting on identifying areas that you did not include in your own SOAP note and discussing why inclusion of those areas …Exam: Constitutional: He appears well-developed and well-nourished. He is active, cooperative and in no acute distress. HEENT: Mouth/Throat: Mucous membranes are moist. No tonsillar exudate. Oropharynx is clear. Pharynx is normal. Nares patent. No cervical lymphadenopathy Eyes: Conjunctiva red bilaterally.Using the information from your HEENT examination of Tina Jones in Shadow Health, write a SOAP note and copy it into the Discussion for Module IV.Your response discussion should be a review of one other student's SOAP note, commenting on identifying areas that you did not include in your own SOAP note and discussing why inclusion of those areas may be important in reaching an appropriate ...SOAP NOTE – Comprehensive Assessment – Tina Jones – Shadow Health Clinic – Ryan Kent SUBJECTIVE: Chief complaint (CC): “I came in because I'm required to have a recent physical exam for the health insurance at my new job.” History of present illness (HPI): Ms. Jones reports that she recently obtained employment at Smith, Stevens, Stewart, Silver …NURS 6512: Assessment of Abdomen and Gastrointestinal System Episodic/Focused SOAP Note. LYMPHATICS: No enlarged nodes. No cervical lymphadenopathy. ALL OTHER SYSTEMS REVIEWED AND NEGATIVE OF PERTINENT FINDINGS. O. Physical exam: Vital signs: B/P 117/59, Pulse 108 (strong and regular); Temp 98.3F orally; RR 18; non-labored; SpO2: 96% room air;SOAP Note. By krenz1as. posted 2021-11-22, updated 2021-11-25. Complete Note. Cite. Favorite 15. approximately 0 views in the last month. ... HEENT exam not performed. HEENT SOAP Note #1. Course. Advanced Practice care of Adults (NURS 6531) ... behind the tympanic membrane upon physical exam that was causing the bulging of the o PE Physical Exam o Physical Examination Terms: Lab Laboratory Studies o Radiology y x-rays y CT and MRI scans y ultrasounds o Assessment- Dx (diagnosis) or DDx (differential diagnosis) if diagnosis is unclear o R/O = rule out (if diagnosis is unclear) o Plan- Further tests, consultations, treatment, recommendations • The “SOAP” Note Shadow Health - HEENT Tina Jones. 53 terms. quizlette1679262. Preview. Shadow Health | Tina Jones | Respiratory Assessment ... EXAM 1 blood dycrasias, mental health ... Aug 23, 2019 · Yes If a medication list was not provided, please give the reason: ***** PHYSICAL EXAM: Blood Pressure: Heart Rate: Respiratory Rate: Weight: Temperature: Pain: GENERAL: Pleasant 46yo white male. NAD. HEENT: TMs with sharp light reflex bilaterally. PERRLA. Diagnosis: M77.12. Lateral Epicondylitis, left elbow. CR is a 54-year-old Caucasian female who presents with pain in her left elbow (dominant hand) with wrist flexion and lateral rotation. She reports worsening pain with any activity that requires these motions and displays a positive Cozen sign on physical exam. She is a retired accountant which …A cytology exam of urine is a test used to detect cancer and other diseases of the urinary tract. A cytology exam of urine is a test used to detect cancer and other diseases of the...Otitis Media Pediatric SOAP Note Example Report. SUBJECTIVE: The patient is a (XX)-month-old female who presents to the pediatrics clinic today with a six-day history of clear rhinorrhea. For the last two days, she has had a low-grade fever, never going above 101, and she has woken up the last two nights pulling at her ears and screaming in pain.Regular dental exams are important for healthy teeth and gums. At most exams, your teeth will be cleaned, and a dentist will check your mouth for problems. Learn more. A dental exa...GENERAL APPEARANCE: Well developed, well nourished, alert and cooperative, and appears to be in no acute distress. HEAD: normocephalic. EYES: PERRL, EOMI. Fundi normal, vision is grossly intact. EARS: External auditory canals and tympanic membranes clear, hearing grossly intact. NOSE: No nasal discharge. THROAT: Oral cavity and pharynx normal.Physical Exam: Vital signs: 37, 120/76, 100, 28, 96% on RA, 4’2”, 90 lbs., BMI General: This is a well-developed, well nourished 8 year old Puerto Rican boy who is alert and cooperative. He is a good historian and answers all health questions appropriately. He coughs every few minutes but is no distress. HEENT: Normocephalic, face ... Shadow Health - HEENT Tina Jones. 53 terms. quizlette1679262. Preview. Shadow Health | Tina Jones | Respiratory Assessment ... EXAM 1 blood dycrasias, mental health ... Intraoral examination reveals moist mucous membranes. There is fractured first tooth with obvious dental tenderness. No surrounding gingival erythema or fluctuance. HEENT medical transcription words and phrases - collection of transcribed samples of HEENT exam found within the physical exam section of medical reports. Using the information from your HEENT examination of Tina Jones in Shadow Health, write a SOAP note and copy it into the Discussion for Module IV.Your response discussion should be a review of one other student's SOAP note, commenting on identifying areas that you did not include in your own SOAP note and discussing why inclusion of those areas …ENT Exam. approximately 217 views in the last month. ENT: Ear canals and tympanic membranes are clear, and hearing is grossly intact. Nose reveals no obstruction or discharge. Oropharynx reveals no inflammation, swelling, exudate or lesion. Lips, teeth and gums are in good general condition. Short Version Long Version. Calculate The Result!Objective. General: Ms. Jones is a pleasant, obese 28-year-old African American woman in no acute distress. She is alert and oriented. She maintains eye contact throughout interview and examination. • Head: Head is normocephalic and atraumatic. Scalp with no masses, normal hair distribution. • Eyes: Bilateral eyes with equal hair ...Do you want to clean up with a soap business of your own? Then take a look at this article showcasing bright and shiny soap businesses on Etsy. If you buy something through our lin...MSN 572 - Week 4 - HEENT SOAP Note.docx. United States University. NURSING MSN572. Week 3 iHuman Amanda Wheaton case.docx. Chamberlain College of Nursing. NR NR509. 2 Gastrointestinal SOAP.docx. ... Left fundoscopic exam reveals sharp disc margins, no hemorrhages. Right fundoscopic exam reveals mild retinopathic changes. …View HEENT soap note.docx from NURSING MSN 572 at United States University. 1 HEENT Soap Note RN, BSN United States University MSN 572- Advanced Health and Physical Assessment Across the Lifespan Dr.Seek medical care if there are any wounds or skin abnormalities to feet. Wash feet with arm water and soap daily and pat dry. Put moisturizing cream or lotion to the tops and bottoms of feet. Wear fitting shoes with dry socks. - Lifestyle changes: Eat fresh fruit, vegetables, whole grains, and low-fat dairy products.Heent SOAP notes. Course: Advanced Health Assessment (NGR 6002) ... Ecp 6705 PS2 - 2018 - Required class notes ; JPA Exam 3 PDF (Crow) PCC Exam 4 - Exam study guide;External auditory canals and tympanic membranes clear bilaterally, hearing grossly intact. No nasal discharge. Oral cavity and pharynx normal. Teeth and gingiva in fair condition. NECK: Supple, non-tender, no adenopathy, masses, or thyromegaly. LUNGS: Clear without rales, rhonchi, wheezing or diminished breath sounds. Good excursions.A breast self-exam is a check-up a woman does at home to look for changes or problems in the breast tissue. Many women feel that doing this is important to their health. A breast s... Obtain a health history related to the head, eyes, ears, nose and throat (HEENT). Perform a physical assessment of the body systems that make up HEENT using correct techniques. Document findings of the HEENT and neck exam. After Immersion, you should be able to: Eyes. Ears. Nose. Mouth. Neck. A comprehensive head and neck exam evaluates the eyes, ears, nose, mouth, throat, and neck. Experienced clinicians may also test the cranial nerves, depending on the chief concern. In Immersion, you will learn cranial nerve testing as part of the Neurologic exam, which we ...Dizziness SOAP Note. Dizziness: Case #1 – Mr. J and BPPV. J is a 32-year-old man who comes to your office complaining of dizziness. J reports that when he is dizzy, it feels as though the room is spinning. His first episode occurred 3 days ago when he rolled over in bed. The spinning sensation was very intense, causing nausea and vomiting. EPISODIC SOAP NOTE HEENT EXAMINATION DOCUMENTATION HurriCaine Spray (benzocaine oral spray) Topical anesthetic-Temporary redness-Stinging-Irritation at the application site -Severe interaction reported with bupivacaine liposomal Numbs the lining of the mouth and throat. Anticipatory guidance, Transfer, Special Instructions, or Collaboration: 1. WK 5 Focused Note Cough Danny Rivera; Tina Jones soap note - Soap note; Week 4 Skin Assignment Picture 2 (Stretch Marks) Focused Episodic SOAP Note for Sore Throat; WK9Assgn 1 The patient is a 70 year old Caucasian female that presents with complaints; WK 10 Assignment 6512- George ASOAP Note- HEENT ID: T ina Jones is an obese 28-year -old African American, who presents to the clinic today with complaints of sore, itchy throat, itchy eyes, and runny nose for the last week.When writing a SOAP note, there are four main sections that should be included: Subjective: This is where the patient’s symptoms and concerns are described. This information is typically gathered through interviews and observation. Objective: This section includes any relevant information that can be observed or measured, such as vital signs ...
Objectives: This chapter will guide the student to: Obtain HEENT health history from the patient. Perform physical assessment of the HEENT and neck using correct techniques. Identify any hearing loss through the use of conversation or if needed the whisper or finger rubbing test. Document findings of the HEENT and neck exam.. Who's the redhead in the old navy commercial
Using the information from your HEENT examination of Tina Jones in Shadow Health, write a SOAP note and copy it into the Discussion for Module IV.Your response discussion should be a review of one other student's SOAP note, commenting on identifying areas that you did not include in your own SOAP note and discussing why inclusion of those areas may be important in reaching an appropriate ... heent [checkbox name="heent" value="face symmetrical with no facial droop|white sclera, conjunctiva pink/red without vision changes, pupils equal and reactive to light|denies:ear pain,drainage from ears, nasal congestion, sore throat, cough, and neck pain|trachea midline without deviation|atraumatic|trauma-active bleeding from ____|trauma-no ...PRIMARY CARE NEW PATIENT HISTORY AND PHYSICAL. approximately 21 views in the last month. -General: Denies wt. changes, fever/chills, fatigue. sore throat/hoarseness or hearing problems. -CV: Denies chest pain, dyspnea, palpitations, edema.Applied HEENT Exam. After the advanced HEENT workshop, you should be able to: Perform the Immersion HEENT exam and interpret your findings. Perform additional problem focused maneuvers: Weber and Rinne tests to differentiate conductive and sensorineural hearing loss. Palpate the sinuses in suspected sinusitis. Inspect the nasal …Objective: The Facts & Figures · Vital signs · Physical exam findings · Laboratory data · Imaging results · Mood and affect · Posture ...Buying bulk dish soap is certainly the way to go for a business that requires regular dishwashing. Here are the best bulk dish soaps for your business. If you buy something through...1228 Exam Formula Sheet for final exam; Soap note cases for Obstetrics clinical hours; FORM Appendix G Individual Evidence Tool copy; Related Studylists lpn Shadow Health Health assessment. Preview text. Tina Jones Shadow health HEENT. Finding:Established chief complaint.View SOAP Note1 HEENT.docx from NRNP 6568 at Walden University. SOAP Note #1: HEENT Kristy Hough Master of Science of Nursing, Walden University PRAC 6531, Section 03, Adv Practice Care of Adults ... Physical exam: General: A.B. is a well-developed, well-nourished Caucasian female who is alert and cooperative.View SOAP note HEENT.docx from NUR 494 at Missouri Western State University. SOAP note Template for Shadow Health Identifying Information:Tina Jones, 28 year old, African American Female. ... Using the information from your HEENT examination of Tina Jones in Shadow Health, write a SOAP note. Responses must be a minimum of 250 words, …Do you want to become a real estate broker? Here are the eight steps that will help you prepare to pass the real estate broker exam. Real Estate | How To Download our exam prep e-b...View SOAP NOTE #3 Tina HEENT.docx from ASSESSMENT NUR 612 at Maryville University. S.O.A.P. Note Template CASE ID#: TINA HEENT EXAM What brought you here today...(eg. headache) Itchy, sore throat withGeneral MSK exam. approximately 231 views in the last month. GEN: Alert and oriented in no acute distress. HEENT: Normocephalic, atraumatic. No lacerations or abrasions. No obvious deformity. No edema or ecchymosis. Non-TTP clavicle, shoulder, arm, elbow, forearm, wrist, or hand. Compartments soft.SOAP Note #1: HEENT Kristy Hough Master of Science of Nursing, Walden University PRAC 6531, Section 03, Adv Practice Care of Adults Across the Lifespan Dr. Donna Fowler, DNP, NP-C, FNP-BC September 17, 2021 By signing, I attest the patient below is an actual patient we see in the clinic.NURS 6512: Assessment of Abdomen and Gastrointestinal System Episodic/Focused SOAP Note. LYMPHATICS: No enlarged nodes. No cervical lymphadenopathy. ALL OTHER SYSTEMS REVIEWED AND NEGATIVE OF PERTINENT FINDINGS. O. Physical exam: Vital signs: B/P 117/59, Pulse 108 (strong and regular); Temp 98.3F orally; RR 18; non-labored; SpO2: 96% room air;PHYSICAL EXAMINATION - Normal. Vital signs: BP 120/80; P 68/min reg; RR 14/min; T 36.9 °C; Wt. 78 kg; Ht 175 cm;. General: Well-developed, well-nourished ...View. PHYSICAL EXAM: GENERAL: well-developed and well-nourished alert and cooperative in no acute distress well-appearing and nontoxic, HEENT: normocephalic atraumatic EOMI vision grossly intact bilaterally no conjunctival injection or visible discharge hearing grossly intact bilaterally no frontal sinus tenderness bilaterally no maxillary ....
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