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NR 511 Week 3 SOAP note

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Patient Information: K, 65 year old, female, insured Subjective Data CC: "cough" HPI: Presents with cough that started a week ago is not getting better, wakes her, cough now causing her chest to ... hurt, points to area on right side that she reports it hurts every time she takes a deep breath. States is more tired, easily winded when walking, decreased energy. Tried some cough syrup which did not stop cough for long. Current Medications: Daily multivitamin, Evista 60 mg daily and HCTZ 25 mg daily. Allergies: Demerol and seasonal allergies to pollen, hay fever. PMHx: Osteopenia, HTN, hyperlipidemia. Childhood illnesses include measles, chicken pox and rubella. No reported past injuries. Hospitalized for childbirth, tonsillectomy and cholecystectomy. Soc Hx: Married, does not work outside the home but takes care of her daughters children and the home. Denies any use of alcohol, illicit drugs or tobacco. Fam Hx: Lives with her husband, her married daughter and her family. ROS Constitutional: Denies weight loss, fever or chills, but reports decreased energy and feeling more tired. HEENT: Denies any headaches or dizziness. Denies any visual changes. Denies any ear pain, hearing loss or ringing in the ears. No reported nasal congestion or discharge. No reported sore throat, or hoarseness but reports cough for the last week. Skin: No reported rashes or itching. Cardiovascular: Reports chest pain due to coughing, no reported palpitations. No reported cardiac history other than HTN. Respiratory: Denies wheezing or shortness of breath with rest. States easily winded when walking. Cough present. Gastrointestinal: No reported n/v, no reported diarrhea, changes in bowels, abdominal pain or discomfort. Denies heartburn and indigestion. Lymphatics: Denies any enlarged lymph nodes. No reported lymph node tenderness or neck stiffness. [Show More]

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