SOAP Note Assignment analyze the attached case study for this week. Create a SOAP note for disease prevention, health promotion, and acute care of the patient

Running head: NAME OF CARE PLAN 1

Title of Plan of Care

Name

South University Online

Faculty Name

NSG 6001

Date

NAME PLAN OF CARE 2

**Please delete this statement and anything in italics prior to submission to shorten the length

of your paper.

Patient Initials ______

Subjective Data: (Information the patient tells you regarding themselves: Biased Information):

Chief Compliant: (In patient’s exact words)

History of Present Illness: (Analysis of current problems in chronologic order using symptom

analysis [onset, location, frequency, quality, quantity, aggravating/alleviating factors, associated

symptoms and treatments tried]).

PMH/Medical/Surgical History: (Includes medications and why taking, allergies, other major

medical problems, immunizations, injuries, hospitalizations, surgeries, psychiatric history,

obstetric and history sexual history).

Significant Family History: (Includes family members and specific inheritable diseases).

Social History: (Includes home living situation, marital history, cultural background, health

habits, lifestyle/recreation, religious practices, educational background, occupational history,

financial security and family history of violence).

Review of Symptoms: (Review each body system – This section you should place POSITIVE for…

information in the beginning then state Denies…). – General:; Integumentary:; Head:; Eyes: ;

ENT:; Cardiovascular:; Respiratory: ; Gastrointestinal:; Genitourinary:; Musculoskeletal:;

Neurological:; Endocrine:; Hematologic:; Psychologic: .

Objective Data:

Vital Signs: BP – ; P ; R ; T ; Wt. ; Ht. ; BMI .

Physical Assessment Findings: (Includes full head to toe review)

HEENT:

Lymph Nodes:

Carotids:

Lungs:

Heart:

Abdomen:

Genital/Pelvic:

Rectum:

Extremities/Pulses:

Neurologic:

Laboratory and Diagnostic Test Results: (Include result and interpretation.)

Assessment: (Include at least 3 priority diagnosis with ICD-10 codes. Please place in order of

priority.)

Plan of Care: (Addressing each dx with diagnostic and therapeutic management as well as

education and counseling provided).

NAME PLAN OF CARE 3

References

Week 2: Respiratory Clinical Case

Patient Setting:

65 year old Caucasian female that was discharged from the hospital 10 weeks ago after a motor vehicle

accident presents to the clinic today. States she is having severe wheezing, shortness of breath and

coughing at least once daily. She can barely get her words out without taking breaks to catch her breath

and states she has taken albuterol once today.

HPI

Frequent asthma attacks for the past 2 months (more than 4 times per week average), serious MVA 10

weeks ago; post traumatic seizure 2 weeks after the accident; anticonvulsant phenytoin started – no

seizure activity since initiation of therapy.

PMH

History of periodic asthma attacks since early 20s; mild congestive heart failure diagnosed 3 years ago;

placed on sodium restrictive diet and hydrochlorothiazide; last year placed on enalapril due to

worsening CHF; symptoms well controlled the last year.

Past Surgical History

None

Family/Social History

Family: Father died age 59 of kidney failure secondary to HTN; Mother died age 62 of CHF

Social: Nonsmoker; no alcohol intake; caffeine use: 4 cups of coffee and 4 diet colas per day.

Medication History

Theophylline SR Capsules 300 mg PO BID

Albuterol inhaler, PRN

Phenytoin SR capsules 300 mg PO QHS

HTCZ 50 mg PO BID

Enalapril 5 mg PO BID

Allergies

NKDA

ROS

Positive for shortness of breath, coughing, wheezing and exercise intolerance. Denies headache,

swelling in the extremities and seizures.

Physical exam

BP 171/94, HR 122, RR 31, T 96.7 F, Wt 145, Ht 5’ 3”

VS after Albuterol breathing treatment – BP 134/79, HR 80, RR 18

Gen: Pale, well developed female appearing anxious. HEENT: PERRLA, oral cavity without lesions, TM

without signs of inflammation, no nystagmus noted. Cardio: Regular rate and rhythm normal S1 and S2.

Chest: Bilateral expiratory wheezes. Abd: soft, non-tender, non-distended no masses. GU:

Unremarkable. Rectal: Guaiac negative. EXT: +1 ankle edema, on right, no bruising, normal pulses.

NEURO: A&O X3, cranial nerves intact.

Laboratory and Diagnostic Testing

Na – 134

K – 4.9

Cl – 100

BUN – 21

Cr – 1.2

Glu – 110

ALT – 24

AST – 27

Total Chol – 190

CBC – WNL

Theophylline – 6.2

Phenytoin – 17

Chest Xray – Blunting of the right and left costophrenic angles

Peak Flow – 75/min; after albuterol – 102/min

FEV1 – 1.8 L; FVC 3.0 L, FEV1/FVC 60%