University of North Texas Nursing Case Study
Description
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Instructions
- Review the following case study.
- Construct a subjective data set for the case study in a Word file from the information provided.
- Structure the subjective data set in the format provided in your lecture materials.
- Submit the Word file containing your subjective data set into Canvas.
- To support your success on the assignment the SOAP Note AssignmentInstructions are attached here for your review of how to structure asubjective data set.
Unit 1 Case Study
A 50-year-old man comes to your office for a routine physical examination. He is a new patient in your practice. He states his father died at the age of 73 of a heart attack. His mother is alive at the age of 80. He has hypertension, and he takes chlorthalidone 25 mg PO daily. Takes Tylenol as needed for pain.Denies seasonal or drug allergies.He has two younger siblings with no known chronic medical conditions.Last eye and dental exam two years ago. He is married in a monogamous relationship without children.Has a high school diploma. Works full-time for a local landscaping business.He does not smoke, use alcohol, or use any recreational drugs.The patient does not exercise. He denies fever, chills, weight loss, or weight gain.He denies hearing changes, headaches, or dizziness.He reports some visual changes when reading close-up.He denies shortness of breath, dyspnea on exertion, swelling, or chest pain.He reports increased urination and thirst.Denies abdominal pain, nausea, vomiting, or changes in appetite.He reports daily BM.Denies rashes or bug bites.Uses sunscreen daily due to working outside. Denies anxiety or depression. On examination, his blood pressure is 126/82, and his pulse is 80 beats/min with a respiratory rate is 18. Height is 67 inches, and weight is 190lbs. Does not appear in acute distress, responses are appropriate and appears to be a reliable source. Alert, oriented to person, place, time, and situation.Well-nourished, skin warm, dry, and intact.Normocephalic.Pupils size 3 mm, equal and reactive to light.Extraocular eye movements are intact in six directions.Tympanic membranes are gray with an adequate cone of light bilaterally.Mucous membranes are pink and moist.No palpable masses, thyromegaly, lymphadenopathy, or JVD.Regular heart rate and rhythm, S1 and S2. No bruits auscultated.Capillary refill less than 3 seconds.Breath sounds clear bilaterally to auscultation.No use of accessory muscles or purse lip-breathing.Soft, non-tender, non-distended, normoactive bowel sound. No organomegaly or guarding.Denies numbness or tingling.He reports he has not had HIV or PSA screenings.
