SOAP NOTE Revise, change and check for plagiarism. SOAP NOTE Name: C.R. Date: 06/05/2018 Time: 14:00 Age: 64 Sex: Female SUBJEC

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SOAP NOTE

Name: C.R.

Date: 06/05/2018

Time: 14:00

 

Age: 64

Sex: Female

SUBJECTIVE

CC: “I have been short of breath for 4 days”

 

HPI:  D.W. is a pleasant 64-year-old female. Patient reports to the clinic with complaints nasal congestion, a runny nose, sore throat, productive cough, and chest tightness and body ache for approximately 4 days. Patient denies any fever. She reports taking OTC ibuprofen 200 mg as needed for body ache.

Medications:

Verapamil ER 240 mg PO daily-Hypertension

Atorvastatin 40 mg orally once daily hyperlipidemia

Multivitamin 1 tablet daily- Supplement

Ibuprofen 200 mg as needed for body pain

PMH-

Allergies:  NKDA

Medication Intolerances: None

Chronic Illnesses/Major traumas: Patient has a history of hypertension and hyperlipidemia

Hospitalizations/Surgeries: C-section x2

Family History-Patient reports that her dad is deceased, Hx: HTN and obesity and that her mother is alive HTN and dementia.

Social History- Patient is retired, she worked as accountant assistance. Patient is married to her second husband, she has two adult sons from her previous married. Patient reports that she quit smoking in 2010 and she drinks alcohol socially.  

ROS

General:

Patient reports that she is not feeling well. Denies any fever or chills. Denies any weight loss. 

Cardiovascular:

Patient denies any chest pain or edema. Denies palpitations, orthopnea. As per member, morning blood pressure was 135/76. 

Skin:

Patient denies any skin rashes, skin discoloration, lesions, or bruising.

 

Respiratory:

Patient reports difficulty breathing, wheezing, productive coughing with green sputum.  

Eyes:

Patient denies any blurred vision or vision changes. Wear glasses all the time.

Gastrointestinal:

 Denies constipation, nausea or vomiting hepatitis, hemorrhoids, ulcers, black tarry stools. Last bowel movement was yesterday.

Ears:

Patient denies any hearing loss, ringing in the ears, or ear pain.

 

Genitourinary/Gynecological:

Patient denies any burning, frequency, or urgency with urination. Patient denies any changes in urine color.  

Nose/Mouth/Throat:

Patient reports sneezing, runny nose, sore throat, and nasal congestion for approximately 4 days.  

Musculoskeletal:

Denies, joint swelling, stiffness or pain, fracture. Denies history of osteoporosis. No assistance to be transfer.

Breast:

Patient denies any lumps, bumps, or changes in her breast.

Neurological:

Patient denies any syncope, weakness, or seizures.

Heme/Lymph/Endo:

Patient denies any bruising, swollen glands, increased thirst, or increased hunger.

Psychiatric:

Patient denies any anxiety, depression, difficulty sleeping, or suicidal ideation or attempts.

OBJECTIVE

Weight   157 lbs.     BMI 26.1

Temp 98.7

BP 137/75

Height 5 feet 5 inches

Pulse 77

Resp 24

General Appearance:

Patient is cooperative, alert, and oriented, and answers questions appropriately. Patient appears to be generally ill.

Skin:

Skin is clean, warm, dry, and intact. No lesions or rashes noted.

HEENT:

Head is normocephalic, atraumatic, and without any lesions. Eyes: PERRLA with EOMs intact. Ears: Bilateral ear canals patent. Bilateral tympanic membranes grey with positive light reflex. Nose: 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: Mild erythema without exudate. Teeth: Patient wearing a full set of dentures.

Cardiovascular:

S1, S2 with regular rhythm and rate. No murmurs or extra sounds heard. Capillary refill 2 seconds and pulses normal throughout. No edema noted.

Respiratory:

Respirations are regular and easy with symmetrical chest rise. Tachypnea noted. Expiratory wheezing noted to left lung, right lung sounds are diminished. No use of accessory muscles noted. Moist and non-productive cough noted.

Gastrointestinal:

Bowel sounds active in all 4 quadrants. Abdomen is obese, soft, and non-tender. No hepatosplenomegaly.

Genitourinary/Gynecological;

Bladder is non-distended, no CVA tenderness. GYN exam deferred.

Musculoskeletal:

Full ROM noted in all 4 extremities. Patient ambulatory with no distress.

Neurological:

Speech is clear with good tone. Balance is stable, normal gait is noted.

Psychiatric:

Patient is alert and oriented x3. Good eye contact noted. Answers questions appropriately. Speech is clear and soft. Patient dressed in clean pants and shirt.

Lab Tests-None 

Special Tests-None 

 Diagnosis

 Differential Diagnoses

· 1-Upper Respiratory Infection (J06.9)

· 2- Streptococcal pharyngitis (J02.0)

· 3-Sinusitis (j32.9)

Diagnosis

· 1-1-Upper Respiratory Infection (J06.9)


Plan/Therapeutics

· Plan: 

Ibuprofen 200 mg orally every 4-6 hours as needed, maximum 2400 mg/day.
Oxymetazoline nasal spray 2 sprays in each nostril q10-12h prn; Max: 6 sprays in each nostril/24h. (Common cold, 2017).

Education: The patient was educated to stay hydrated by drinking plenty of fluids. The patient was also educated to take medications as prescribed (Common cold, 2017). The patient reported that her vaccines were up to date and she was encouraged to remain up to date with all her vaccines.

Non-medication treatments: None

Return to clinic: The patient was instructed to return to clinic if symptoms did not improve or if symptoms became worse.

This encounter allows me the opportunity to review the differential diagnoses and final diagnosis. I was able to independently assess the patient and ROS. I also educated the patient in the treatment plan. The importance establishes an open communication with our clients. After this encounter I was able to verbalize understanding of the treatment plan for this condition.

Reference

Common cold. (2017, August 08). Retrieved from https://www.mayoclinic.org/diseases-

conditions/common-cold/symptoms-causes/syc-20351605

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