Nu610-U1 case study

  • 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 Assignment Instructions are attached here for your review of how to structure a subjective data set.

A 50-year-old man comes to your office for a routine physical examination. He is a new patient to yourpractice. 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, which 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 medicalconditions. Last eye and dental exam two years ago. He is married in a monogamous relationshipwithout children. Has a high school diploma. Works full-time for local landscaping business. He doesnot smoke, drink alcohol, use any recreational drugs and does not exercise. He denies fever, chills,weight loss or weight gain. He denies hearing changes, headaches or dizziness. He reports some visualchanges when reading close-up. He denies shortness of breath, dyspnea on exertion, swelling or chestpain. He reports increase urination and thirst. Denies abdominal pain, nausea, vomiting or changes inappetite. He reports daily BM. Denies rashes or bug bites. Uses sunscreen daily due to workingoutside. Denies anxiety or depression. On examination his blood pressure is 126/82, pulse is 80beats/min, respiratory rate is 18. Height is 67 inches and weight is 190lbs. Does not appear in acutedistress, responses are appropriate and appears reliable source. Alert, oriented to person, place, timeand situation. Well-nourished, skin warm, dry and intact. Normocephalic. Pupils size 3 mm, equal andreactive to light. Extraocular eye movements intact to six directions. Tympanic membranes gray withadequate cone of light bilaterally. Mucous membranes pink and moist. No palpable masses,thyromegaly, lymphadenopathy or JVD. Regular heart rate and rhythm, S1 and S2. No bruitsauscultated. Capillary refill less than 3 seconds. Breath sounds clear bilaterally to auscultation. No useof accessory muscles or purse lip-breathing. Soft, non-tender, non-distended, normoactive bowelsound. No organomegaly or guarding. Denies numbness or tingling. He reports he has not had HIV orPSA screenings.

Are you struggling to create a sound and comprehensive nursing paper? Do you feel overwhelmed with the amount of time and effort it takes to write a good piece? Are you looking for the best nursing paper writing service that can assist you in your nursing paper needs? Look no further than our skilled team of professional writers who specialize in providing high-quality papers with the best nursing paper writing services reviews. Make your order at

Needs help with similar assignment?

We are available 24x7 to deliver the best services and assignment ready within 3-4 hours? Order a custom-written, plagiarism-free paper

Get Answer Over WhatsApp Order Paper Now