SOAP note Essay
I.Subjective Data
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Write My Essay For MeA.Chief Complain (CC): Patient stated she hasn’t felt very well for the past week. She complains of cough both day and night and it has kept her awake. She states she has coughed up some yellow-greenish phlegm that seems to be getting worse. Patient states there has been no blood in her sputum. Denies any fever, runny nose, chest pain, nausea or vomiting. Patient states she does get short of breath with exertion.
B.History of Present Illness (HPI): Patient is a 56 year- old white female who presents to the ER with history of productive cough for the past 6 days.
C.Last Menstrual Period (LMP- if applicable): Hysterectomy in 4/2011 and no cycle since surgery.
D.Allergies: No know allergies.
E.Past Medical History: Hypertension-controlled with Atenolol 25mg
F.Family History: Hypertension
G.Surgery History: 4/2011 Hysterectomy
H.Social History (alcohol, drug or tobacco use): Denies use of alcohol, illicit drugs or tobacco
I.Current medications: Atenolol 25mg PO QD, OTC Sudaphed HBP BID for the past 4 days.
J.Review of Systems (Remember to inquire about body systems relevant to the chief complaint and HPI)
II.Objective Data
Vital Signs/ Height/Weight: Patient is 5 feet 7 inches and 175 pounds. Her
blood pressure today is 128/70, heart rate 72, respiratory rate 16, temperature 99.6.
General Appearance: Her mucous membranes are moist without any abnormal findings. Tympanic membranes area clear and no signs of any type ear infection are noted. Her pharynx is somewhat erythematous but is without swelling, exudates or signs of postnasal drainage.
HEART: Heart sounds are normal. No s/s of edema noted in her extremities.
RESP: Bilateral lower lung fields have Rhonchi which clear when patient coughs. Her inspiratory effort is good but her rate increases when she cannot stop coughing.
A.Assessment
Differential Diagnosis (National Lung, Heart and Blood Institute, 2012)
1. Impaired gas exchange related to bronchitis
Rationale: Identifies alterations from usual breathing pattern and influences choice of intervention.
2. Airway Obstruction
Rationale: Quality of cough and ability to raise secretions including consistency and characteristics of sputum – removal of secretions prevents obstruction of airways and stasis leading to further infection and consolidation of lungs; clearing airways facilitates breathing.
3. Tachypnea
Rationale: Decreasing the rate of respirations can halt the “blowing off” of CO2, elevating PaCO2 level and normalizing pH.
Medical Diagnosis
1. Acute bronchitis (Wenzel, R., 2012). Acute Bronchitis most likely caused by recent ore ongoing upper airway viral infection.
B: PLAN
1.Prescriptions: Albuterol Inhaler two puffs BID, disp: one inhaler with no refills. Promethazine/codeine syrup one tsp BID as needed for cough, disp: 30ml with no refills. 2.Diagnostic testing: None with current visit.
3.Problem orientated education: During the use of the gas stove in their home I suggested the use of a vaporizer. Breathing moist air from a humidifier, hot shower, or sink filled with hot water. The heat and moisture can help keep mucus in your airways moist so it can be coughed out easily. Complete recovery within 7-10 days in most patients should occur. Instruct patient the cough may persist up to 10-14 days after the start of prescribed medication. 4.Health Promotion/Maintenance Needs: Increase fluids to at least 64oz of water per day to help with drainage. Avoiding caffeine and alcohol, which cause you to lose extra fluid from your body and may lead to dehydration. 5.Cultural & Life span considerations: Patient appears to be a well-adjusted Caucasian American female who exhibits no signs and symptoms of anxiety or depression related to her acute illness. Her husband is present and appears supportive. Her husband understands the plan of care provided to the patient. Patient routinely attends a local Baptist church but has no spiritual needs at this visit. 6.Referrals: None with current visit.
Follow-Up Plans: Follow up appointment in 3 days if cough worsens or fever increases. Upon follow-up visit if needed, will order chest x-ray. Follow up appointment in 3-4 weeks to ensure acute bronchitis has resolved, administer flu vaccination and pneumonia vaccination
