*NURSING > SOAP NOTE > 1.SOAP Note Week 2 Respiratory.pdf.DOC (All)

1.SOAP Note Week 2 Respiratory.pdf.DOC

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Patient Information: Tina Jones is an obese 28-year-old African American female, who comes in today for evaluation and treatment of asthma exacerbation. S. CC (chief complaint) “I came in because I� ... ��ve been having breathing problems, and my inhaler just isn’t working the way it normally does.” HPI: include all the information regarding the CC using the OLDCART format.Albuterol 90 mcg/spray 3 puffs every four hours as needed for wheezing when around cats Allergies: Penicillin= rash Cats and dust= runny nose, itchy and swollen eyes and increased asthma symptoms Ms. Jones denies any food or latex allergiesTina reports her sister also has asthma. Denies any family history of COPD, or any throat or neck surgeries. Her mother is living and has high cholesterol and hypertension. Her father passed away in a car accident a year ago. Father had high cholesterol, hypertension and type 2 diabetes. Her bother is obese and her sister has asthma. Tina denies any family history of eczema or COPD. [Show More]

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