chamberlain college of nursing nr 601 week 7 soap note nr601 week 7 soap note new
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NR 601 (NR601)
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NR 601 Week 7 Soap Note
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 years 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
treatment for his cancer and his wife and children are in disagreement with him.
The patient wants to know what his options are for the remainder of his life.
Family history: Unknown
Family Hx : unknown
ROS
Constitutional symptoms – denies fever and chills, denies significant weight loss
or weight gain.
HEENT: denies any visual loss, blurred vision, and double vision. No drainage or
exudate in ears. No hearing loss, no sneezing, congestion and runny nose, no
sore throat. Denies any nasal issues.
Cardiovascular – denies syncope, denies chest pain.
Pulmonary – denies hemoptysis, no labored respirations, no cough, : rhonchi in
anterior chest bilaterally.
Gastrointestinal – denies nausea, vomiting, or diarrhea. RUQ tenderness; liver
palpable
Musculoskeletal –denies crepitus, No muscle atrophy or asymmetry, no joint
discomfort
Genitourinary: denies urine frequency, or bladder problem,
Neurological – denies headaches, dizziness, or lightheadedness.
Psychiatry: Alert and oriented
O:
Vital Signs:
Height: 6’0 Weight: 140 pounds; BMI: 19.0 BP: 156/84 P: 84 regular R: 20
Physical Exam
HEENT: normocephalic, symmetric PERRLA, EOMI; poor dentition
NECK: left neck supple; non-palpable lymph nodes; no carotid bruits. Limited
ROM
LUNGS: rhonchi in anterior chest bilaterally.
HEART: S1 and S2 audible; regular rate and rhythm
ABDOMEN: active bowel sounds all 4 quadrants; Normal contour; RUQ
tenderness; liver palpable
NEUROLOGIC: negative
GENITOURINARY: negative
MUSCULOSKELETAL: negative
PSYCH: PHQ-9 is 15
SKIN: oral mucosa irritated-stomatitis
A.
Primary Diagnosis
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