SOAP_NOTE_Rheumatoid_Arthritis.doc
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Denies delayed healing, rashes, bruising, bleeding or skin discolorations, any changes in lesions or moles Denies cough, wheezing, dyspnea at this time Eyes Corrective lenses Gastrointestinal De... nies abdominal pain, N/V/D, constipation, hepatitis, hemorrhoids, eating disorders, ulcers, black tarry stools Ears Denies ear pain, hearing loss, ringing in ears, discharge Genitourinary/Gynecological Denies urgency, frequency burning, change in color of urine, vaginal discharge or STDS. Hysterectomy 5 years ago. Last mammography 1 years ago. G2, P2, A0 Nose/Mouth/Throat Denies sinus problems, dysphagia, nose bleeds or discharge, dental disease, hoarseness, and throat pain Musculoskeletal Localized symptoms in hand joints: pain, tender, swollen, and decrease range of motion. Breast SBE every month, denies lumps, bumps or changes Neurological Denies syncope, seizures, transient paralysis, weakness, paresthesias, black out spells Heme/Lymph/Endo Denies HIV status, bruising, blood transfusion hx, night sweats, swollen glands, increase thirst, increase hunger, cold or heat intolerance Psychiatric Denies depression, anxiety, sleeping difficulties, suicidal ideation/attempts, previous dx OBJECTIVE Weight: 139 BMI: 23.9 Temp: 98.2 BP: 127/79 Height: 5’4 Pulse: 84 Resp: 16 General Appearance Healthy appearing adult female in no acute distress. Alert and oriented; answers questions appropriately. Skin Skin is white, warm, dry, clean and intact. No rashes. HEENT Head is normocephalic, atraumatic and without lesions; hair evenly distributed. Eyes: PERRLA. EOMs intact. No conjunctival or scleral injection. Ears: Canals patent. Bilateral TMs pearly grey with positive light reflex; landmarks easily visualized. This study source was downloaded by 100000816392744 from CourseHero.com on 04-21-2021 15:21:51 GMT -05:00 https://www.coursehero.com/file/30170766/SOAP-NOTE-Rheumatoid-Arthritisdoc/ [Show More]
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