NR 531 Episodic SOAP Note: Tom Walker COMPLETE ANSWER KEY 2023.

NR 531 Episodic SOAP Note: Tom Walker COMPLETE ANSWER KEY 2023. University of Phoenix Collage of Nursing – Online Campus NPR 531 ADVANCED HEALTH ASSESSMENT I 2 2/ 2 Running head: Episodic SOAP Note: Tom Walker Episodic SOAP Note: Tom Walker DOS: 10/14/18 ID: Tom Walker (M) DOB: 1/3/75 (45) CC: Atopic Dermatitis (eczema) Right Knee Injury Subjective HPI: Mr. Tom Walker is a 45-year old is a Caucasian male who appears well groomed and a reliable historian. He presents today with itching has been so bad that it is keeping him awake at night, and his skin has little cracks that bleed. He has been using OCT hydrocortisone cream for flares. His eczema flare in the bend of his arms is (9/10). He loves to take hot showers, but notices he itches more after them. He has had these flareups on occasion in the past. HPI: Tom injured his right knee while playing basketball 4 days ago. He hasn’t been able to bear weight on his knee and is using crutches. He felt a “pop” and had to be carried off the floor. The swelling and bruising are intense. He has been using ice, resting, elevating his knee, and wearing an ace bandage on his knee for support. He reports pain (7/10). He has been taking Tylenol XS. Past Medical Hx: Meniscus Tear 2009 Surgical Hx: Tom had a meniscus repair with a scope on the same knee in 2009. He also had an appendectomy last August. Family Hx: His mother has elevated cholesterol and his brother is obese with high blood pressure. Medications: NKDA OTC hydrocortisone cream, Tylenol® XS Social Hx: He is a non-smoker but reports smoking pot one time in college. He drinks about 4– 6 beers per night. Tom’s mother is an RN in New Jersey Education Level: College Graduate Objective PE: VS: BP - 120/78 P - 70 R - 16 T - 98.2 HT:72’ WT:250# BMI: 33.9. General: He is a well-nourished, well developed male who appears in distress as evidence by being unable to bear weight on his knee and is using crutches. HEENT: Pupils are equal, round, and reactive to light and accommodation 2 2/ 3 Running head: Episodic SOAP Note: Tom Walker CV: Normal S1, S2; no S3, S4 with no murmurs or extra sounds Pulm: Breath sounds clear; no wheezes, rales, or rhonchi noted Abdomen: Bowel sounds active in all quadrants; soft, non-tender to palpation; nondistended. Pt denies differences in vision, double vision, blurry vision; no congestion, no hearing loss; no chest pain, SOB, heart palpitations; no changes in appetite; no changes in mood or memory. Relevant specialty tests: No tests with Atopic Dermatitis Lachman’s test- the patient lays on the table with leg bent at a 30-degree with the foot flat, and if the knee moves freely without reaching a firm point is a tear (Bickley, L. S., Szilagyi, P. G., & Bates, B., 2017). Pivot shift test- the injured leg is extended, and the foot is rotated at the same time as pressure is applied to the outside of the knee as the knee is bent. Instability in the tibia suggests an ACL tear (Hong, E., Kraft M.C., 2014). Right knee x-ray to r/o fracture (Domino, F.J., Baldor R.A., Golding, J., Stephens, M., 2018). 5 Open-Ended Questions Mr. Walker how long have you had Atopic Dermatitis (eczema)? The onset of atopic dermatitis in childhood is most common in patients, and onset after 30 is very uncommon. What treatments have you tried in the past that have made your symptoms better or worse? Patients with atopic dermatitis should not bath more than once daily. Do you have any family history of allergic reactions? Establishes if patient has a family sensitivity to irritants. When do you notice that you flare ups tend to occur? Atopic individuals are sensitive to low humidity and often flare in the winter (Thomsen, S.F., 2014). Have you had a previous knee injury prior to four days ago? Establishes history of previous injury, and potential reinjury. Have you noticed any pain or noises with walking? Locking or