Class Nurs 505- Advanced Health Assessment I

Class Nurs 505- Advanced Health Assessment I need to write a soap note for a HEENT exam. The attached pdf is the example we were given. I’m not sure what exactly is meant by the last section where they ask us to discuss nursing theory, health promotion, family ilfe diversity and evaluation. any ideas? 1 attachment View all attachment SOAP example: Skin/Hair/Nails SUBJECTIVE Ms. P is a pleasant, 33-year-old, single, African American, recently unemployed computer programmer with a chief complaint of thinning hair and diffuse itching. History of Present Illness : Client has noticed scalp hair thinning, and increasing pruritis without rash in her scalp, back, arms, face, and neck over the past year. Scalp thinning pattern is reported to be diffuse, not in patches or clumps. Denies eyebrow or eyelash thinning. No hx of thyroid disease, and states her TSH was checked x 2 in the past year and reported normal both times. Has not noticed any alleviating or aggravating factors for the hair thinning. Itching is worse in heat (weather, household temperature, or exercise). Partial, temporary relief with cool shower, with gradual resolution over ~1 hr. General body sx occur ~ every two or three months, and scalp itching flares after a perm. Client states that the scalp itching interferes with sleep the day of her perm. No personal or family hx of asthma or eczema. Reports mother with significantly thinned scalp hair starting around age 40. PMHx : “Healthy”. No medical problems known. No surgeries. Medications : None Allergies : NKDA OBJECTIVE PE: General: 142# BP 124/80 p 80 T 98.1 HEENT : Head : Comment on symmetry and any tenderness Eyes : Conjunctiva: Sclera: Pupils: EOMs: Ophthalmoscope: Eyelids: Eyebrows: Ears : TM’s: Canals: Weber: Rinne: Nose : Septum: Nasal mucosa: Maxillary and frontal sinuses: Throat/Neck : Oral mucosa: Uvula: Tonsils: Gums: Tongue: Trachea: Neck: Comment on lymphadenopathy presence/absence and what nodes are enlarged if applicable. Thyroid : Cardiac : Basic cardiac exam: Comment on rate/rhythm, presence/absence of murmur(s)

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