Characteristics Of Nurse Soap Notes

1170 WordsSep 28, 20175 Pages
Nurse Practitioner SOAP Notes SUBJECTIVE DATA: Chief Complaint (CC): Bad headache History of Present Illness (HPI): Patient is an 18 y/o AAF who presents with a BP of 169/80 and a bad headache of 2-day duration. Pain is 10/10 and throbs all over her head, without relief, gradually increasing in intensity until the current severe state. Movement makes it worse, nothing makes it better. Took OTC Tylenol then Aleve without relief of symptoms. Denies trauma, ear pain, or nasal drainage. Does not have a cough and is not SOB. No neck stiffness or sore throat. Has not had a fever but admits she did not check it. She has not been around anyone sick nor has any household member been ill. She's never had allergies, sinus infections or…show more content…
Stable gate, appropriate mood, holding head in hands with occasional grimace. BP noted to be elevated, up from previous visit 2 weeks ago 164/75 mm Hg. HEENT: Normocephalic and atraumatic. No bumps or bruising. No sinus tenderness or palpable lymph nodes. Eyes: Clear without drainage, PERRLA, no fundus abnormalities or papilledema. Ears: Good acuity, no tenderness, canal without inflammation or cerumen bilaterally. TM is grey with no bulging. Nose: Nares patent, no edema or discharge. Throat: Membranes pink and moist. Neck: Supple, no thyromegaly. Trachea midline. Chest/Lungs: Clear to auscultation and percussion. No rhonchi, crackles, wheezing or stridor Heart/Peripheral Vascular: Normal S1/S2, regular rhythm, capillary refill < 3 sec. Tachypneic. Trace edema bilateral lower extremities. Neurological: A/O x3, answers question appropriately, follows commands and CN II-XII intact. Good strength, reflexes and sensation. Appropriate affect and mood. ASSESMENT: Differential Diagnosis (Essential Hypertension) Positives: three elevated BP's, excess weight, smoking (history of), sedentary, salt, ethnicity, family history, diabetes, headache Negatives:
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