*NURSING > QUESTIONS & ANSWERS > NURS 6512 Week 7: Heart, Lungs, & Peripheral Vascular System Episodic/Focused SOAP Assessment Note. (All)

NURS 6512 Week 7: Heart, Lungs, & Peripheral Vascular System Episodic/Focused SOAP Assessment Note. Graded A

Document Content and Description Below

Week 7: Heart, Lungs, & Peripheral Vascular System Episodic/Focused SOAP Assessment Note Patient Information: H.H., 65, M, Caucasian CC “I have been having shortness of breath over the last fe... w days, and getting worse” HPI: The patient is a 65-year-old Caucasian male who presents with respiratory (lungs) shortness of breath upon exertion (walking) or while resting. The shortness of breath began a few days ago. The patient does not state specific characteristics but does note associated signs and symptoms of a productive cough with thick, greenish occasional blood tinged sputum, with no specific timing of the day. The patient has noted that it is getting worse but does not indicate the duration of the SOB when it begins. However, there is a noted increase in tiredness associated, and that walking specifically makes it worse, and nothing relieves the shortness of breath. The patient does not note any pain associated, but notes chills, insomnia, and possible fever, so Tylenol 650 mg over the counter was taken by the patient for the fever. Current Medications: OTC: Tylenol 650 mg po Q6 hr prn fever or mild pain Allergies: NKDA (food/environment) PMHx: No history provided of medical, surgical, hospitalizations, immunizations, or any currently prescribed medications. Soc Hx: H.H. is married, unknown if has children; currently smokes 3 cigarettes per day- has attempted several times to quit. Fam Hx: No family history provided. Review of Systems: GENERAL: Fever, chills, sweats; feels tired all the time; no weight loss HEENT: Eyes: wears glasses. Ears, Nose, Throat: No hearing loss, sneezing, or, runny nose. SKIN: No rash or itching. [Show More]

Last updated: 2 years ago

Preview 1 out of 7 pages

Buy Now

Instant download

We Accept: