SOAP NOTE BY 06/10/2022 AT 6 PM

answer
ATTACHED FILE(S)
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%
Running head: NAME OF CARE PLAN1

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

Place your order
(550 words)

Approximate price: $22

Calculate the price of your order

550 words
We'll send you the first draft for approval by September 11, 2018 at 10:52 AM
Total price:
$26
The price is based on these factors:
Academic level
Number of pages
Urgency
Basic features
  • Free title page and bibliography
  • Unlimited revisions
  • Plagiarism-free guarantee
  • Money-back guarantee
  • 24/7 support
On-demand options
  • Writer’s samples
  • Part-by-part delivery
  • Overnight delivery
  • Copies of used sources
  • Expert Proofreading
Paper format
  • 275 words per page
  • 12 pt Arial/Times New Roman
  • Double line spacing
  • Any citation style (APA, MLA, Chicago/Turabian, Harvard)

Our guarantees

Delivering a high-quality product at a reasonable price is not enough anymore.
That’s why we have developed 5 beneficial guarantees that will make your experience with our service enjoyable, easy, and safe.

Money-back guarantee

You have to be 100% sure of the quality of your product to give a money-back guarantee. This describes us perfectly. Make sure that this guarantee is totally transparent.

Read more

Zero-plagiarism guarantee

Each paper is composed from scratch, according to your instructions. It is then checked by our plagiarism-detection software. There is no gap where plagiarism could squeeze in.

Read more

Free-revision policy

Thanks to our free revisions, there is no way for you to be unsatisfied. We will work on your paper until you are completely happy with the result.

Read more

Privacy policy

Your email is safe, as we store it according to international data protection rules. Your bank details are secure, as we use only reliable payment systems.

Read more

Fair-cooperation guarantee

By sending us your money, you buy the service we provide. Check out our terms and conditions if you prefer business talks to be laid out in official language.

Read more