SOAP NOTE
Identify: C.R.
Date: 06/05/2018
Time: 14:00
Age: 64
Intercourse: Feminine
SUBJECTIVE
CC: “I’ve been wanting breath for Four days”
HPI: D.W. is a nice 64-year-old feminine. Affected person reviews to the clinic with complaints nasal congestion, a runny nostril, sore throat, productive cough, and chest tightness and physique ache for roughly Four days. Affected person denies any fever. She reviews taking OTC ibuprofen 200 mg as wanted for physique ache.
Drugs:
Verapamil ER 240 mg PO daily-Hypertension
Atorvastatin 40 mg orally as soon as each day hyperlipidemia
Multivitamin 1 pill daily- Complement
Ibuprofen 200 mg as wanted for physique ache
PMH-
Allergic reactions: NKDA
Remedy Intolerances: None
Persistent Sicknesses/Main traumas: Affected person has a historical past of hypertension and hyperlipidemia
Hospitalizations/Surgical procedures: C-section x2
Household Historical past-Affected person reviews that her dad is deceased, Hx: HTN and weight problems and that her mom is alive HTN and dementia.
Social Historical past- Affected person is retired, she labored as accountant help. Affected person is married to her second husband, she has two grownup sons from her earlier married. Affected person reviews that she stop smoking in 2010 and he or she drinks alcohol socially.
ROS
Basic:
Affected person reviews that she will not be feeling nicely. Denies any fever or chills. Denies any weight reduction.
Cardiovascular:
Affected person denies any chest ache or edema. Denies palpitations, orthopnea. As per member, morning blood stress was 135/76.
Pores and skin:
Affected person denies any pores and skin rashes, pores and skin discoloration, lesions, or bruising.
Respiratory:
Affected person reviews problem respiratory, wheezing, productive coughing with inexperienced sputum.
Eyes:
Affected person denies any blurred imaginative and prescient or imaginative and prescient modifications. Put on glasses on a regular basis.
Gastrointestinal:
Denies constipation, nausea or vomiting hepatitis, hemorrhoids, ulcers, black tarry stools. Final bowel motion was yesterday.
Ears:
Affected person denies any listening to loss, ringing within the ears, or ear ache.
Genitourinary/Gynecological:
Affected person denies any burning, frequency, or urgency with urination. Affected person denies any modifications in urine colour.
Nostril/Mouth/Throat:
Affected person reviews sneezing, runny nostril, sore throat, and nasal congestion for roughly Four days.
Musculoskeletal:
Denies, joint swelling, stiffness or ache, fracture. Denies historical past of osteoporosis. No help to be switch.
Breast:
Affected person denies any lumps, bumps, or modifications in her breast.
Neurological:
Affected person denies any syncope, weak point, or seizures.
Heme/Lymph/Endo:
Affected person denies any bruising, swollen glands, elevated thirst, or elevated starvation.
Psychiatric:
Affected person denies any nervousness, despair, problem sleeping, or suicidal ideation or makes an attempt.
OBJECTIVE
Weight 157 lbs. BMI 26.1
Temp 98.7
BP 137/75
Top 5 toes 5 inches
Pulse 77
Resp 24
Basic Look:
Affected person is cooperative, alert, and oriented, and solutions questions appropriately. Affected person seems to be usually in poor health.
Pores and skin:
Pores and skin is clear, heat, dry, and intact. No lesions or rashes famous.
HEENT:
Head is normocephalic, atraumatic, and with none lesions. Eyes: PERRLA with EOMs intact. Ears: Bilateral ear canals patent. Bilateral tympanic membranes gray with optimistic gentle reflex. Nostril: Nasal mucosa pink, turbinates mildly enlarged, no septal deviation. Neck: Supple. Full ROM. No cervical lymphadenopathy, no thyromegaly or nodules. Oral mucosa: Moist and pink. Pharynx: Gentle erythema with out exudate. Tooth: Affected person sporting a full set of dentures.
Cardiovascular:
S1, S2 with common rhythm and price. No murmurs or further sounds heard. Capillary refill 2 seconds and pulses regular all through. No edema famous.
Respiratory:
Respirations are common and straightforward with symmetrical chest rise. Tachypnea famous. Expiratory wheezing famous to left lung, proper lung sounds are diminished. No use of accent muscle mass famous. Moist and non-productive cough famous.
Gastrointestinal:
Bowel sounds lively in all Four quadrants. Stomach is overweight, smooth, and non-tender. No hepatosplenomegaly.
Genitourinary/Gynecological;
Bladder is non-distended, no CVA tenderness. GYN examination deferred.
Musculoskeletal:
Full ROM famous in all Four extremities. Affected person ambulatory with no misery.
Neurological:
Speech is evident with good tone. Steadiness is steady, regular gait is famous.
Psychiatric:
Affected person is alert and oriented x3. Good eye contact famous. Solutions questions appropriately. Speech is evident and smooth. Affected person wearing clear pants and shirt.
Lab Checks-None
Particular Checks-None
Prognosis
Differential Diagnoses
· 1-Higher Respiratory An infection (J06.9)
· 2- Streptococcal pharyngitis (J02.zero)
· Three-Sinusitis (j32.9)
Prognosis
· 1-1-Higher Respiratory An infection (J06.9)
Plan/Therapeutics
· Plan:
Ibuprofen 200 mg orally each Four-6 hours as wanted, most 2400 mg/day. Oxymetazoline nasal spray 2 sprays in every nostril q10-12h prn; Max: 6 sprays in every nostril/24h. (Widespread chilly, 2017).
Training: The affected person was educated to remain hydrated by ingesting loads of fluids. The affected person was additionally educated to take drugs as prescribed (Widespread chilly, 2017). The affected person reported that her vaccines had been updated and he or she was inspired to stay updated with all her vaccines.
Non-medication therapies: None
Return to clinic: The affected person was instructed to return to clinic if signs didn’t enhance or if signs grew to become worse.
This encounter permits me the chance to evaluate the differential diagnoses and ultimate prognosis. I used to be capable of independently assess the affected person and ROS. I additionally educated the affected person within the therapy plan. The significance establishes an open communication with our shoppers. After this encounter I used to be capable of verbalize understanding of the therapy plan for this situation.
Reference
Widespread chilly. (2017, August 08). Retrieved from https://w
