SOAP notes on Mr. HN, 65 years old male assignment

SOAP notes on Mr HN, 65 years old male assignment

Exam Results: Scenario 2 Mr. HN, 65 years old male.Vital signs: Temperature: 97.9 oral Respiratory rate: 32, labored Heart rate: 112, tachycardic BP right arm: 148/88 Oxygen saturation: 90% on room air Weight: 210 lbs, stable Skin: Cool, diaphoretic Thorax and lungs: Thorax symmetrical; diminished breath sounds right middle and lower lobes; no rales, rhonchi, or wheezes; breath sounds vesicular with no adventitious sounds left lung Cardiovascular: Heart rate is irregular with good S1, S2; no S3 or S4; no murmur Abdomen: Protuberant with normoactive bowel sounds auscultated x4 quadrants Peripheral vascular: Right calf with 2+ edema, erythema; warmth and tenderness on palpation noted; left lower extremity without edema or erythema; 2+ dorsalis pedis pulses bilaterally Neurologic: Anxious; awake, alert, and oriented to person, place, and time;

SOAP notes on Mr HN, 65 years old male assignment

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• Review this week\’s Learning Resources and consider the insights they provide.
• Consider what history would be necessary to collect from the patient.
• Consider what physical exams and diagnostic tests would be appropriate to gather more information about the patient\’s condition. How would the results be used to make a diagnosis?
• Identify at least five possible conditions that may be considered in a differential diagnosis for the patient.
• Diagnostic text and lab work for DVT
• evaluate abnormal findings in the area of the chest and lungs. In addition, you will appraise health assessment techniques and diagnoses for the heart, lungs, and peripheral vascular system

SOAP notes on Mr HN, 65 years old male assignment

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