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.Soap.Note.Respiratory.TinaJones.pdf 2020

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nformation the patient or patient representative told you. Initials: T. J. Age: 28 Gender: Female Height: 170cm Weight: 86kg BMI: 30.8 BP: 140/81 BG: 224 RR: 20 HR: 89 Temp: 98.5 SPO2: 97% Pain (1-10) ... : Denies LMP: 1/14/20- irregular; every 2 moths; or 6 times a year Allergies: YES Medication: Penicillin- rash/hives Food: Denies Environment: Cats and dust- itchy watery eyes, running nose, exacerbates asthma wit sneezing and wheezing. History of Present Illness (HPI) “It feels like it’s been hard to take in air. My chest feels all tight and I’ve been wheezing. I’ve had to use my inhaler a lot, and it doesn’t feel like it’s totally working”. Chief Complaint (CC): Chest tightness inhaler not working Onset: IntermitSocial History Living with her mother in the suburbs, helping her family and saving money to get her own place. Drinks alcohol when out with friends, two or three drinks; Drives a motor vehicle uses her seatbelt Reports low activity level and diminished activity due to asthma. She uses hypoallergenic bedding hygiene, avoids animals and has not pets in the home. She works fulltime and is in school fulltime. Finds support through family, church, and friends. She is helping her mother since her father is deceased a year ag [Show More]

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