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NR601 week7soap
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Soap note Week 7 S. CC.: HPI: C.G. is a 69-year-old male with a history of right head and neck cancer. His cancer was diagnosed 2 years ago at which point he decided to stop smoking Onset: 2 yea... rs ago Location: head and neck, left lingual tonsil region Duration: Ongoing, 2 year Characteristics: supple neck, limited ROM to neck, rhonchi in anterior chest bilateral, metabolic activity in the left lymph node area along with other regions of abnormal metabolic activity in the body, RUQ tenderness Aggravating Factors: Tiredness from chemotherapy and radiation, oral mucosa irritated-stomatitis. Relieving factors: unknown Treatment: 6 weeks of radiation and chemotherapy, right radical neck dissection, 2012. Severity: liver and the lungs metastasis Current medications: Carvedilol 12.5 mg po 1 daily Furosemide 40 mg po daily Allergies: no known drug allergies. PMHx, Hypertension Hyperlipidemia Stomatitis Anemia Neutropenia Surgeries: right radical neck dissection , 2012 vaccination history include: Influenza vaccine last received 1 year ago Received pneumovax at age 65 Received Tdap 5 years ago Has not had the herpes zoster vaccine Social history and Risk Factors: Former smoker-stopped smoking at the time his cancer was diagnosed-2 years ago Negative for alcohol intake or drug use Patient does not have an advanced directive or living will. He is refusing further [Show More]
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