Utilize the SOAP guidelines to assist you in creating your SOAP note and building your plan of care. You are expected to develop a comprehensive SOAP note based on the given assessment, diagnosis, and advanced nursing interventions. If the information is not in the provided scenario please consider it normal for SOAP note purposes, if it is abnormal please utilize what you know about the disease process and write what you would expect in the subjective and objective areas of your note.
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Week 2: Respiratory Clinical Case Patient Setting: 65 year old Caucasian female that was discharged from the hospital 10 weeks ago after a motor vehicle accident presents to the clinic today. States she is having severe wheezing, shortness of breath and coughing at least once daily. She can barely get her words out without taking breaks to catch her breath and states she has taken albuterol once today. HPI Frequent asthma attacks for the past 2 months (more than 4 times per week average), serious MVA 10 weeks ago; post traumatic seizure 2 weeks after the accident; anticonvulsant phenytoin started – no seizure activity since initiation of therapy. PMH History of periodic asthma attacks since early 20s; mild congestive heart failure diagnosed 3 years ago; placed on sodium restrictive diet and hydrochlorothiazide; last year placed on enalapril due to worsening CHF; symptoms well controlled the last year. Past Surgical History None Family/Social History Family: Father died age 59 of kidney failure secondary to HTN; Mother died age 62 of CHF Social: Nonsmoker; no alcohol intake; caffeine use: 4 cups of coffee and 4 diet colas per day. Medication History Theophylline SR Capsules 300 mg PO BID Albuterol inhaler, PRN Phenytoin SR capsules 300 mg PO QHS HTCZ 50 mg PO BID Enalapril 5 mg PO BID Allergies NKDA ROS Positive for shortness of breath, coughing, wheezing and exercise intolerance. Denies headache, swelling in the extremities and seizures. Physical exam BP 171/94, HR 122, RR 31, T 96.7 F, Wt 145, Ht 5’ 3” VS after Albuterol breathing treatment – BP 134/79, HR 80, RR 18 Gen: Pale, well developed female appearing anxious. HEENT: PERRLA, oral cavity without lesions, TM without signs of inflammation, no nystagmus noted. Cardio: Regular rate and rhythm normal S1 and S2. Chest: Bilateral expiratory wheezes. Abd: soft, non-tender, non-distended, no masses. GU: Unremarkable. Rectal: Guaiac negative. EXT: +1 ankle edema, on right, no bruising, normal pulses. NEURO: A&O X3, cranial nerves intact. Laboratory and Diagnostic Testing Na – 134 K – 4.9 Cl – 100 BUN – 21 Cr – 1.2 Glu – 110 ALT – 24 AST – 27 Total Chol – 190 CBC – WNL Theophylline – 6.2 Phenytoin – 17 Chest Xray – Blunting of the right and left costophrenic angles Peak Flow – 75/min; after albuterol – 102/min FEV1 – 1.8 L; FVC 3.0 L, FEV1/FVC 60%