Normal breast exam soap note
WebBreasts: Exam in the supine position with no masses, no lumps, and no nipple discharge. Abdomen: Soft, nontender to palpation with no hepatosplenomegaly or masses palpated. … WebNo palpable hepatosplenomegaly. Extremities: Peripheral circulation is normal with no evidence of clubbing and cyanosis. No edema bilaterally. No varicosities noted. …
Normal breast exam soap note
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Web22 de ago. de 2024 · Background. The role of radiographic screening for breast cancer ( mammography) in women younger than 50 years is controversial. Physical examination … WebEyes: Sclera white, normal light sensitivity and no abnormal discharge, no redness. Ears: Bilaterally intact, TM intact, no discharge. Nose: Pink and Moist mucosa, no sneezing or excessive discharge or congestion, no polyps. Throat: No Inflammation, swelling or dislocation. Nurs 6551: Primary Care of Women – Sample SOAP Note.
http://www.annualreport.psg.fr/DYxJ_well-woman-exam-soap-note.pdf WebDocumentation of Breast Assessment Patient has the presence of both breasts, relatively equal in size with right breast slightly larger than the left. The breasts are round, color is …
WebTechnique. With patient supine, place right hand on patient's abdomen, just lateral to the rectus abdominis, well below lower border of liver dullness. Ask patient to take a deep breath and try to feel the liver edge as it descends. Be sure to allow liver to pass under the fingers of your right hand, note texture. Pressing too hard may interfere. Web3 de ago. de 2024 · A SOAP (subjective, objective, assessment, plan) note is a method of documentation used specifically by healthcare providers. SOAP notes are used so staff can write down critical information concerning a patient in a clear, organized, and quick way. SOAP notes, once written, are most commonly found in a patient’s chart or electronic …
Web30 de jan. de 2024 · Assessment is the first and most critical phase of the nursing process.Incorrect nursing judgment arises from inadequate data collection and may adversely affect the remaining phases of the nursing process: diagnosis, planning, implementation, and evaluation.Get the complete picture of your patient’s health with this …
Web11 de jan. de 2024 · Fundi normal, vision is grossly intact. EARS: External auditory canals and tympanic membranes clear, hearing grossly intact. NOSE: No nasal discharge. … cts scotlandWebOlder adults may also be less able to sense touch, pressure, vibration, heat, and cold. [12] When completing an integumentary assessment it is important to distinguish between expected and unexpected assessment findings. Please review Table 14.4b to review common expected and unexpected integumentary findings. cts screenerWebNeurological SOAP Note. Barbra Scheirer Regis College NU 650- Advanced Health Assessment Professor T. Hewitt November 28, 2024. Neurological SOAP Note Date: 11/247/2024 1530 hrs.Patient name: S. Race/Ethnicity: Black DOB: 3/15/ Age: 64Y F Marital Status: Married SUBJECTIVE Chief Complaint (CC): "My face is drooping” History of … earweb.comWeb• Integumentary: No rash, no lesions, no abnormal moles noted. M/M moist, skin turgor good. Warm and dry to touch, no swelling noted. Pulses present +2 equal bilaterally. o … earwed18nvWeblevel, normal nipples, areola and skin Normal female breasts: Note similar size and shape, nipples at the same level, normal nipples, areola and skin Normal nippple and areola … cts scottsboro alWeb26 de nov. de 2010 · Testes descended bilaterally. No hernia present. Spine: Straight with no lesions. Joints: Hips with full range-of-motion; negative Barlow and Ortolani. … cts seat coversWeb3 de mar. de 2024 · OB Postpartum SOAP Note. S: Pt denies complaints. A moderate amount of lochia, no clots, voiding well, ambulating PRN, + flatus, no BM yet, denies … ear weaving piercing