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Brown_ Susan_NR509_Week 2_SOAP_Note

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SOAP Note Template Initials: TJ Age: 28 Gender: Female Height Weight BP HR RR Temp SPO2 Pain Allergies 170cm 89kg 140/ 81 89 20 98.5 97% Medication: Penicilllin- rash/hives; as a child Food: NKFA Environment: Cats and dust- itchy watery eyes,runny nose, exacerbates asthma History of Present Illness (HPI) Chief Complaint (CC) “Breathing problems” CC is a BRIEF statement identifying why the patient is here - in the patient’s own words - for instance "headache", NOT "bad headache for 3 days”. Sometimes a patient has more than one complaint. For example: If the patient presents with cough and sore throat, identify which is the CC and which may be an associated symptom Onset Diagnosed with asthma at age 2 and ½ years; exacerbation two days ago Location Chest and lungs Duration Two days ago. Episodes occurring approximately every 4 hours or “5 times a day” Characteristics SOB not well relieved by inhaler, DOE, wheezing, difficulty breathing while lying flat, dry cough, waking at night due to SOB Aggravating Factors Expsosure to cats and dust. Bursts of physical exertion “run up stairs to class.” “Past couple of days, though it doesn’t seem like anything in particular is causing it.” Relieving Factors Pronventil inaler. “Once I use my inhaler it only takes a minute or two for my breathing to go back to normal…that’s not what’s been happening recently , though.” Treatment Proventil inhaler Current Medications: Include dosage, frequency, length of time used and reason for use; also include OTC or homeopathic products. Medication (Rx, OTC, or Homeopathic) Dosage Frequency Length of Time Used Reason for Use Proventil 90mcg 2 inhalations Every 4 hours prn 25.5 years Asthma: wheezing, SOB Tylenol 500mg 2 tablets po Every 6 hours prn PRN Headache Advil 200mg 3 tablets po Every 4 – 6 hours prn PRN Menstrual cramps Click or tap here to enter text. Click or tap here to enter text. Click or tap here to enter text. Click or tap here to enter text. Click or tap here to enter text. Click or tap here to enter text. Click or tap here to enter text. Click or tap here to enter text. Click or tap here to enter text. Click or tap here to enter text.

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