[SOLVED] NR-509 Week 2 Respiratory SOAP Note

SOAP Note Template Initials: TJ Age: 28 Gender: Female Height Weight BP HR RR Temp SPO2 Pain Allergies 170cm 89kg 140/ .5 F 97% Medica tion: Penicillin (rash/hives) Food: none Environment: Cats History of Present Illness (HPI) Chief Complaint (CC) “chest tightness” 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 Intermittent chest tightness the last couple of days after being near cats Location Chest tightness all over Duration Intermittently the past two days Characteristics Chest tightness no pain. Aggravating Factors Worse at night and lying down, cats, and dust. Relieving Factors Albuterol inhaler Treatment Proventil 90mcg inhaler 3 puffs every 4 hours. 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 Proventil (albuterol) Inhalation 90mcg per puff (2-3 puffs) PRN for asthma symptoms Q 4hrs Wheezing and dyspnea N/A 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. N/A 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. N/A 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. N/A 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. Asthma dx age 2.5 yrs old, Diabetes dx at 24yrs old,Denies surgical history, last hospital admission at 16 yrs old for asthma exacerbation. Reports all Immunization are current at this visit, Last Flu vaccine: declines at this time Last Tetanus booster: last year 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. Supervisor at Mid-American Copy & Ship, Bachelor’s accounting student, Hobbies: hanging with friends and going to church. Close with mother and sister (living together), Brother lives elsewhere, father deceased from car accident. Denies tobacco use. Alcohol use socially with friends ( rum and diet coke drink of choice). Drives and uses seatbelt, working smoke detector in house. 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- high cholesterol and hypertension Father (deceased at 58 car accident)- T2DM, high cholesterol and hypertension Brother 25 y.o.- Obesity Sister 14 y.o -Asthma maternal grandma- HTN and high cholesterol maternal grandpa-HTN and high cholesterol. paternal grandma-HTN and high cholesterol paternal grandpa- (deceased) colon cancer, HTN, diabetes. 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 Denies ☐ Weakness Denies ☐ Fever/Chills Denies ☐ Weight Gain Denies changes ☐ Weight Loss Denies ☒Trouble Sleeping Reports trouble sleeping lately ☐ Night Sweats Denies ☐ Itching Denies ☐ Rashes Denies ☐ Nail Changes Denies ☒Skin Color Changes Reports skin around neck darker and breaking out on face and little on back. ☒Other: ☐ Diplopia Denies ☐ Eye Pain Denies ☐ Eye redness Denies ☐ Vision changes Denies ☐ Photophobia Denies ☐ 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: Click or tap here to enter text. ☐ Other: Click or tap here to enter text. Reports moles on back not new. Respiratory Neuro Cardiovascular ☒Cough Reports cough with no sputum ☐ Hemoptysis Denies ☒Dyspnea Reports trouble catching breath ☒Wheezing Reports intermittent wheezing ☐ Pain on Inspiration Denies ☐ Sputum Production ☐ Other: Click or tap here to enter text. ☐ Syncope or Lightheadedness Denies ☐ Headache Denies ☐ Numbness Denies ☐ Tingling Denies ☐ Sensation Changes ☐ Speech Deficits Denies ☐ Other: Click or tap here to enter text. ☐ Chest pain Denies ☒SOB Intermittent when going up stairs or walking ☒Exercise Intolerance reports unable to exercise due to shortness of breath ☒Orthopnea Reports short of breath worse when lying down at night ☐ Edema Denies ☐ 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 ☐ Swelling Denies ☐ Limited ROM ☐ Redness Denies ☐ Misalignment Denies ☐ Other: Click or tap here to enter text. ☐ Nausea/Vomiting Denies ☐ Dysphasia Denies ☐ Diarrhea Denies ☐ 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. ☐ Urgency Denies ☐ Dysuria Denies ☐ Burning Denies ☐ Hematuria Denies ☐ Polyuria Denies ☐ Nocturia Denies ☐ Incontinence Denies ☐ Other: Click or tap here to enter text. ☐ Stress Denies ☐ Anxiety Denies ☐ 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 Denies ☐ Dysmenorrhea Denies ☐ Foul Odor Denies ☐ Amenorrhea Denies ☐ LMP: Did not assess ☐ Contraception Denies ☐ Other:Click or tap here to enter text. Body System Positive Findings Negative Findings General Click or tap here to enter text. Patient is alert and oriented, normal stature Skin Moles assessed on right upper back, skin discoloration of neck, and observed facial acne. Click or tap here to enter text. HEENT Click or tap here to enter text. Click or tap here to enter text. Respiratory Neuro Auscultated adventitious breath sounds bilaterally, in posterior lower lobes, wheezing noted in bilateral posterior, lower lobes. Click or tap here to enter text. Chest inspection: symmetrical, Palpated: equal expansion bilaterally, expected fremitus, Percussed Chest wall : No dullness, Auscultated: normal breath sound in anterior upper and lower lobes. Click or tap here to enter text. Cardiovascular Click or tap here to enter text. Click or tap here to enter text. Musculoskeletal Click or tap here to enter text. Click or tap here to enter text. Gastrointestinal Click or tap here to enter text. Click or tap here to enter text. Genitourinary Click or tap here to enter text. Click or tap here to enter text. This stuPdsy ysocurhceiawtarsidcownloaded by from CourseH on :54:13 GMT -06:00 Click or tap here to enter text. Click or tap here to enter text. 1. Chest tightness 6 Click or tap here to enter text. 11 Click or tap here to enter text. 2 Wheezing 7 Click or tap here to enter text. 12 Click or tap here to enter text. 3 shortness of breath 8 Click or tap here to enter text. 13 Click or tap here to enter text. 4 Click or tap here to enter text. 9 Click or tap here to enter text. 14 Click or tap here to enter text. 5 Click or tap here to enter text. 10 Click or tap here to enter text. 15 Click or tap here to enter text. 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. Diagnosis ICD-10 Code Pertinent Findings Mild intermittent asthma, with acute exacerbation J45.21 Symptoms started after cat exposure, Reports feeling better after use of inhaler on and off. Wheezing R06.2 Reports wheezing and Ausculatated wheezing in the posterior bilateral lower lobes of patient lungs. Shortness of breath R06.02 Reports trouble catching breath P: Plan DAidadgrensossatillc5s:paLritsst otef sthtse ycoomu pwreillhoerndseivrethtriesavtmiseitnt plan. If you do not wish to order an intervention for any part of the treatment plan, write “None at this timeT” ebsut do not leave any heading blank. No intervention is self-evidentR. Patriovniadle /aCritattiionale and evidence-based in-text citation for AeBacGh intervention. To check if patient is well oxygenated (mendes, 2019). 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. Click or tap here to enter text. Click or tap here to enter text. Click or tap here to enter text. Medications: List medications/treatments including OTC drugs you will order and “continue previous meds” if pertinent. Drug Dosage Length of Treatment Rationale/Citation Continue previous meds Click or tap here to enter text. Click or tap here to enter text. Click or tap here to enter text. Albuterol inhalation 90mcg PRN Bronchodilation (Mendes, 2019). PO Salbutamol 4mg PRN for bronchospasm According to Sottas, Anderson, & Holford (2016), Salbutamol is a selective beta-2 adrenoreceptor agonist widely used for the treatment of bronchospasm. 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. Click or tap here to enter text. Click or tap here to enter text. Click or tap here to enter text. Referral/Consults: Respiratory consult Rationale/Citation Make sure the patient is taught proper inhaler technique to ensure they are using their inhalers correctly (Mendes, 2019). Education: Teach about right medication administration and give proper inhaler instructions. Rationale/Citation Inhaler prescriptions must be accompanied by discussions about proper technique and the establishment of an asthma action plan (Mendes, 2019). Follow Up: Indicate when patient should return to clinic and provide detailed instructions indicating if the patient should return sooner than scheduled or seek attention elsewhere. Follow up at the clinic in 2 week if not better. If symptoms of wheezing or shortness of breath worse, seek medical attention and go to the ER if after hours and in case of an emergency. Keep a list of symptoms on when to seek medical attention and emergency numbers on the fridge. Rationale/Citation According to Mendes (2019), patients are taught to check in regularly with their action plan and even advised to keep a copy of it on their phone and/or fridge. References Include at least one evidence-based peer-reviewed journal article which relates to this case. Use the correct APA 6th edition formatting. Mendes, A. (2019). Raising the bar in asthma management. British Journal of Community Nursing, 24(9), 456–457. https://doi-