VITAL SIGNS WHILE LYING SUPINE BP=122/80 MMHG, HR=82, RR=12BPM, TEMP=98.2° YOU ASK THE PATIENT TO SIT UP IN PATIENT BED TO RETAKE HIS BLOOD PRESSURE AND LISTEN TO HIS LUNGS (HE TELLS YOU HE CAN SIT UP...

I am having a hard time doing a soaps note with the following information for my medical terminology class.

 REVISIT PATIENT COMPLAINTS AND ANY EVALUATIVE INFORMATION • DEVELOP PROBLEM LIST AND DIFFERENTIAL DIAGNOSIS • WHAT IS YOUR DIAGNOSTIC PLAN? • WHAT IS YOUR THERAPEUTIC PLAN? • PATIENT EDUCATION?

Extracted text: VITAL SIGNS WHILE LYING SUPINE BP=122/80 MMHG, HR=82, RR=12BPM, TEMP=98.2° YOU ASK THE PATIENT TO SIT UP IN PATIENT BED TO RETAKE HIS BLOOD PRESSURE AND LISTEN TO HIS LUNGS (HE TELLS YOU HE CAN SIT UP ON HIS OWN) EVALUATION BP=98/64 MMHG BLOOD PRESSURE DECREASE OF 20 MM HG OR A DI CONTINUED BLOOD PRES EREASE OF M HG WITHIN MINUTES OF STANDING LUNG SOUNDS NORMAL SKIN WITHOUT BLUE TINGE OF COLOR, FLUID ACCUMULATION UNDER THE SKIN, OR ABNORMALLY PALE COLOR OF THE SKIN.


Extracted text: NURSING ADMISSION NOTE: patient number: QU3876 • Pt. is a 30 y/o male who lives alone in an apartment with primary complaint of decreased functional mobility. Pt. was recently treated at the urgent care center located in the local Walmart following a fall while CHART getting out of bed the week before. He was taken to the center by his friend that lives in the same building. REVIEW Secondary complaints of: intermittent headache • High sensitivity to pain • Tingling feeling • Passing out English Speaking