NR-509 Week 2 Respiratory SOAP Note

Document Content and Description Below

SOAP Note Template Initials: TJ Age: 28 Gender: female Height Weight BP HR RR Temp SPO2 Pain Allergies 170cm 89kg 140/ 81 89 20 98.5 97% Medication: penicillin-rash/hives Food: none Environment... : Seasonal, Dust, Cats- sneezing, wheezing, itchy eyes, pruritis History of Present Illness (HPI) Chief Complaint (CC) “Shortness of Breath” CC is a BRIEF statement identifying why the patient is here - in the patient’s own words - for instance "headache", NOT "bad headache for 3 days”. Sometimes a patient has more than one complaint. For example: If the patient presents with cough and sore throat, identify which is the CC and which may be an associated symptom Onset 2 days ago Location Chest, Lungs Duration Every four hours since original exacerbation, each episode lasting several minutes Characteristics Chest tightness, difficulty taking air in, wheezing, coughing, not relieved with use of inhaler Aggravating Factors Exertion, dust, cats, lying down Relieving Factors Rest, inhaler, avoidance of allergens Treatment Albuterol Inhaler Current Medications: Include dosage, frequency, length of time used and reason for use; also include OTC or homeopathic products. Medication (Rx, OTC, or Homeopathic) Dosage Frequency Length of Time Used Reason for Use Click or tap here to enter text. Click or tap here to enter text. Click or tap here to enter text. Click or tap here to enter text. Click or tap here to enter text. Albuterol Inhaler 90mcg-2 puffs Q4h prn Two days Asthma Tylenol OTC extra strength 500mg PRN Intermittent Headache Advil OTC 600mg (takes 3 200mg tablets) PRN Intermittent Menstrual cramps Click or tap here to enter text. Click or tap here to enter text. Click or tap here to enter text. Click or tap here to enter text. Click or tap here to enter text. Past Medical History (PMHx) – Includes but not limited to immunization status (note date of last tetanus for all adults), past major illnesses, hospitalizations, and surgeries. Depending on the CC, more info may be needed. S: Subjective Information the patient or patient representative told you Past Medical History: Diabetes Melittus; Asthma: diagnosed at age 2.5years, HTN Vaccinations:Resports being up to date with Pneumonia vaccine : 1 year ago; Tetanus Vaccine: 1 year ago. No current with Flu vaccine. Reports that all childhood vaccines were received. Past surgical history: None Past hospital admissions: 3mo since last physical and check up.; apx. 5 hospital admissions for asthma exacerbations; Last admission related to astma was when patient was 16. Social History (Soc Hx) - Includes but not limited to occupation and major hobbies, family status, tobacco and alcohol use, and any other pertinent data. Include health promotion such as use seat belts all the time or working smoke detectors in the house. Marital Status: Single; Current birth control methods: Abstinance; History of PO birth control (Last used 2 years ago) Occupation: Works as a supervisor at Mid-American copy and shit Education: attending college to obtain a bachelor’s degree in accounting. Living arrangements: Lives with mother and sister. Hobbies: Enjoys reading watching tv series and documentaries Religion: Active in local church Substance use: Denies tobacco use and current recreactional drug use. Reports marajuanna use 3 years ago Drinks alcohol socially (apx twice a month). Last alcoholic beverage, 3 weeks ago. Family History (Fam Hx) - Includes but not limited to illnesses with possible genetic predisposition, contagious or chronic illnesses. Reason for death of any deceased first degree relatives should be included. Include parents, grandparents, siblings, and children. Include grandchildren if pertinent. Mother: Hypertension, High cholesterol Father: (Deceased) at age 58 in mva: HTN, Type II DM, high cholesterol Paternal Grandfather: (Deceased): Colon CA. Type II DM, HTN, high cholesterol Paternal Grandmother: HTN, high cholesterol Maternal Grandmother: HTN, high cholesterol Maternal Grandfather: (Deceased): Cardiovascular Accident. HTN, High cholesterol Sister: Asthma Brother: No health history Review of Systems (ROS): Address all body systems that may help rule in or out a differential diagnosis Check the box next to each positive symptom and provide additional details. Constitutional Skin HEENT ☒Fatigue recent-due to waking up coughing at night ☐Weakness denies ☐Fever/Chills denies ☐Weight Gain denies ☐Weight Loss denies ☒Trouble Sleeping due to coughing ☐Night Sweats denies ☐Other: Click or tap here to enter text. ☒Itching with exposure to cats ☐Rashes denies ☐Nail Changes denies ☒Skin Color Changes skin on neck ☐Other: Click or tap here to enter text. ☐Diplopia denies ☐Eye Pain denies ☐Eye redness denies ☒Vision changes worsening vision over past 2 years ☐Photophobia Click or tap here to enter text. ☐Eye discharge denies ☐Earache denies ☐Tinnitus denies ☐Epistaxis denies ☐Vertigo denies ☐Hearing Changes denies ☐Hoarseness denies ☐Oral Ulcers denies ☐Sore Throat denies ☐Congestion denies ☐Rhinorrhea denies ☒Other: runny nose on occasion Respiratory Neuro Cardiovascular ☒Cough with asthma past two days ☐Hemoptysis denies ☒Dyspnea Click or tap here to enter text. ☒Wheezing Click or tap here to enter text. ☐Pain on Inspiration denies ☐Sputum Production ☐Other: denies sputum ☐Syncope or Lightheadedness denies ☒Headache on occasion ☐Numbness denies ☐Tingling denies ☐Sensation Changes ☐Speech Deficits denies ☐Other: Click or tap here to enter text. ☒Chest pain during astma attack ☒SOB Click or tap here to enter text. ☒Exercise Intolerance Click or tap here to enter text. ☒Orthopnea Click or tap here to enter text. ☐Edema Click or tap here to enter text. ☐Murmurs denies ☐Palpitations denies ☐Faintness denies ☐OC Changes denies ☐Claudications denies ☐PND denies ☐Other: Click or tap here to enter text. MSK GI GU PSYCH ☐Pain denies ☐Stiffness denies ☐Crepitus denies ☐Nausea/Vomiting denies ☐Dysphasia denies ☐Diarrhea denies ☐Urgency denies ☐Dysuria denies ☐Burning denies ☒Stress managed by attending church and talking ☐Anxiety denies ☐Swelling denies ☐Limited ROM ☐Redness denies ☐Misalignment denies ☐Other: Click or tap here to enter text. ☐Appetite Change denies ☐Heartburn denies ☐Blood in Stool denies ☐Abdominal Pain denies ☐Excessive Flatus denies ☐Food Intolerance denies ☐Rectal Bleeding denies ☐Other: Click or tap here to enter text. ☐Hematuria denies ☒Polyuria reports high water intake ☒Nocturia Click or tap here to enter text. ☐Incontinence denies ☐Other: Click or tap here to enter text. ☐Depression denies ☐Suicidal/Homicidal Ideation denies ☐Memory Deficits denies ☐Mood Changes denies ☐Trouble Concentrating denies ☐Other: Click or tap here to enter text. GYN ☐Rash denies ☐Discharge denies ☐Itching denies ☒Irregular Menses menses every 6 weeks to 2 months ☒Dysmenorrhea reports very heavy periords with severe cramps ☐Foul Odor denies ☐Amenorrhea denies ☐LMP: denies ☐Contraception Previously: Denies current use ☒Other:Abstinence/ not currently sexually active O: Objective Information gathered during the physical examination by inspection, palpation, auscultation, and palpation. If unable to assess a body system, write “Unable to assess”. Document pertinent positive and negative assessment findings. Body System Positive Findings Negative Findings General Patient alert/ oriented x4; Well groomed/kept; Distress, Odor Skin Acanthosis nigricans, Acne Cyanosis, palor, vascular discoloration, wounds, lesions, diaphoresis HEENT Watery eyes, runny nose, voice clear Redness or eyes, nose, throat; Visual or auditory aid; Respiratory Symmetric chest expansion, bilateral and equal fremitus, lung sounds and resonance in all lung fields, Wheezing and fine crackles in bilateral middle and lower lung fields, cough Evidence of trauma, pectus excavatum, use of accessory muscles or intercostal retraction while breathing, stridor, rhonchi, rales. Neuro Orientation, free movement in all extremities Confusion, hallucinations, aphasia, paresthesia, memory loss, dizziness Cardiovascular Respiratory distress, fatigue Jugular vein distention, edema, vascular discoloration Musculoskeletal Free movement of extremeties Inflammation/ swelling of joints, deformities Gastrointestinal Rounded Evidence of gastrostomy, surgeries, taut appearance Genitourinary Click or tap here to enter text. Click or tap here to enter text. Psychiatric Pleasant but concerned about breathing; Hallucinations, anxiety, depression Problem List 1. Asthma 6. Knowledge Deficit of HTN 11 Click or tap here to enter text. 2 . Diabetes 7 . Knowledge Deficit of Diabetes 12 Click or tap here to enter text. 3 . Hypertension 8 Click or tap here to enter text. 13 Click or tap here to enter text. 4 . Obesity 9 Click or tap here to enter text. 14 Click or tap here to enter text. 5 . Dysmenorreha 10 Click or tap here to enter text. 15 Click or tap here to enter text. Diagnosis ICD-10 Code Pertinent Findings Asthma J45.909 Wheezing, coughing, tightness in chest, shortness of breath; Exacerbated by dust, allergens, exercise, stress, and worsening of symptoms at night. Diabetes E11.65 Elevated blood glucose readings, Acanthosis nigricans, positive family history,, history of taking metformin Hypertension RO3.0 High blood pressure reading without the presence of a diagnosis of hypertension, family history of hypertension, Diagnostics: List tests you will order this visit Test Rationale/Citation CXR To rule out other causes for cough and respiratory distress, such as an infectious process, cardiac dysfunction, or pneumothorax. (Ash & Diaz, 2017). Spirometry To measure the amount of air inhaled and exhaled from an individual. After a patient takes a full breath in, a TLC or total lung capacity is measured; A forced vital capacity (FCV) can be measured by measuring the amount of air pushed out on expiration. A residual volume (RV), is then measured, when the lungs have been emptied. In an asthmatic patient, this procedure is completed. A treatment of a bronchodilator can then be administered to open the airways. A repeat test is then completed. An A: Assessment Medical Diagnoses. Provide 3 differential diagnoses which may provide an etiology for the CC. The first diagnosis (presumptive diagnosis) is the diagnosis with the highest priority. Provide the ICD-10 code and pertinent findings to support each diagnosis. P: Plan Address all 5 parts of the comprehensive treatment plan. If you do not wish to order an intervention for any part of the treatment plan, write “None at this time” but do not leave any heading blank. No intervention is self-evident. Provide a rationale and evidence-based in-text citation for each intervention. improvement of the pulmonary function testing after administration of a bronchodilator can aid in the diagnosis and treatment effectiveness for asthmatic patients. (Dempsey and Scanlon, 2018). FeNo Testing FeNo testing uses a device to measure the amount of exhaled nitric oxide, which in an individual during an asthmatic event, will elevate as the inflammation in the airways causes the nitric oxide levels to increase. ( Asthma and Allergy Foundation of America (AAFA), 2019). Provocation (Trigger) Test Administered to the patient is small doses of an irritant, to assess for asthma triggers, exercise, to assess for activity intolerance, and methacholine, to assess for other causes of respiratory distress. (AAFA, 2019). Peak Flow Meter Testing The patient will be instructed and given a peak flow meter for testing how well air is moving in and out of the lungs. This meter may be beneficial in noting if the patient is nearing an asthmatic event, and also if medications are successful. (AAFA, 2019). Medications: List medications/treatments including OTC drugs you w [Show More]

Last updated: 1 year ago

Preview 1 out of 11 pages