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Soap Note Sample | Nursing Paper Writing Help Online

ID: The patient is a 40 years old female high school English teacher. The patient is not married.

Chief Complaint: Continuous cough (“I have a continuous cough running for ten days”).

History of present illness (HPI): Ms. Tina presents to the clinic with a chief complaint of continuous coughing. The cough developed ten days ago and was accompanied by a fever up to 100.3 PO. There has been occasional coughing up of green sputum, which has worsened over the last two days due to blood in the sputum. In addition, there has been increased shortness of breath, difficulty sleeping at night and ear pain. The continuous coughing had led to an intermittent headache for the last five days, relieved by acetaminophen. The patient denies any current sinus congestion, sore throat, palpitations, diarrhea, constipation, dysuria or extremities swelling. The patient confirms the use of over-the-counter medications, which did not alleviate the cough. Although her co-workers are also sick, Ms. Tina denies any recent travel trips.

Past Medical History: The patient has a past medical history of hypertension and hypersensitive lung disease.

Past Surgical History:  Reports she had her tonsils and adenoids removed.

Family History:

Father: Hypertension, hyperlipidemia, obesity, deceased at age 75 from Colon Cancer.

Mother: Diabetes Type 2 and hypertension, living at age 80.

Brother: Deceased at age 24 from a motor vehicle accident.

Sister: Diabetes Type 2, hypertension, living at age 52.

Maternal Grandfather: Deceased at age 54 of a heart attack.

Maternal Grandmother: Deceased at age 65 of breast cancer.

Paternal Grandfather: Deceased at age 85 old age.

Paternal Grandmother: Deceased at age 78 of pneumonia.

Son: Healthy, living at age 26, no known health issues.

Daughter: Asthma, living at age 19.

Social History: The patient reports she attained a bachelor’s degree and is a Christian. She reports consuming balanced diets every day and regular exercise thrice a week. The patient enjoys yoga and social work. The patient reports she has smoked one packet of cigarettes since the age of 21. In addition, the patient reports drinking 2-3 alcoholic beverages (beer) per week. Denies marijuana, cocaine, heroin, or other illicit drugs.

Medications:

Lisinopril (Prinivil) 20mg PO daily, last dose 0800 (taken for HTN prescribed for one year).

Atorvastatin (Lipitor) 20mg PO daily at bedtimes, last dose 2200 yesterday (taken for HLD prescribed for one year)

Omega-3 Fish Oil 1200mg PO BID, last dose 0800 (OTC supplement for HDL)

Allergies: Codeine (reports nausea and vomiting). Denies food, environmental, or latex allergy.

 

 

Review of Systems:

General: The patient reports gaining weight over the last couple of years. Report’s anxiety and difficulty in sleeping due to the recent continuous cough. The patient denies fever, chills, fatigue, weakness, night sweats, dizziness, lightheadedness or syncope.

Head: Reports intermittent headaches.

Eyes: Denies eye pain, vision loss or blurred vision.

Ears: Reports ear pain. Denies ear discharge and hearing loss.

Nose/Sinus: denies sinus congestion and nasal discharge.

Mouth/Throat: Denies sore throat and oral sores.

Neck: Denies presence of neck pain. Full range of neck motion noted.

Respiratory: Report’s cough, shortness of breath with exertion. The patient also confirms the presence of blood-tinged sputum. Denies pain on deep inspiration

CV: Ms. Tina confirms chest pains but denies syncope, tachycardia, palpitations or orthopnea.

Gastrointestinal: Denies abdominal pain, nausea, vomiting, loss of appetite, diarrhea, or constipation.

Genitourinary: Ms. Tina denies irregular urine frequency but reports dysuria.

Peripheral vascular: Denies presence of pallor, paresthesia, pulselessness, poikilothermia and gangrene.

Musculoskeletal: The patient denies joint pains and lower extremity edema.

Hematologic: Denies bleeding disorder, lymphadenopathy and hypercoagulability.

Endocrine: Ms. Tina denies polydipsia, polyphagia, polyuria and environmental change intolerance.

Skin: No rashes, lesions, skin itch or skin color change.

Neurologic: Denies headache, dizziness, loss of vision. Denies loss of sensation, numbness, or tingling.

Mental Health: The patient reports increased anxiety levels, insomnia and low-stress levels. Ms. Tina is developmentally appropriate.

Physical Exam:

General appearance: Ms. Tina is generally good in appearance, has no cognitive deficit and has a pleasant mood. The skin is warm and dry, and no tenting is found on examination.

Vital Signs: T, BP, P, R, Ht, Wt, 02 Sat’s, blood glucose. Any pertinent diagnostic test results.

Current temperature is 36.7C, B/P 146/90; pulse rate is 60 beats per minute, respiratory is 19, height 5’11”, weight 197lbs, 02 saturation 98% and blood glucose is 140 mg/dL. Ms. Tina’s current BMI is 27.5.

HEENT: Point of maximal impulse found to be displaced laterally, with brisk tapping, and a diameter of less than 3cm.

Neck: No neck pain or limited range of motion found. No jugular vein distention was found. JVD is 3cm above the sternal angle. A bruit is auscultated in the right carotid artery, with a positive thrill and amplitude of 3+. No bruit was found in the left carotid artery, with no thrill and amplitude of 2+.

Lymph nodes: Palpate lymph nodes using a circular motion to identify pain, induration or swollen ganglia.

Chest: Lung sounds are clear in bilateral anterior lung fields. Lung sounds are clear in posterior upper lung fields, with fine crackles in bilateral posterior lower lung fields. Note for any lesions. Palpate the chest area, noting the presence of masses or points of tenderness. Percuss the chest identifying areas of dullness or masses in malignancy. Auscultate the chest, noting any adventitious breath sounds.

Cardiac: S1-S2, without murmur or rubs. PMI displaced laterally, S3 noted at the mitral area. ECG was performed and found Mr. Foster to be in normal sinus rhythm with no ST changes. Chest pain was noted only with physical activity.

Abdomen: Round, soft, non-tender with normoactive bowel sounds in 4 quadrants; No bruits noted of the abdominal aorta. No tenderness or masses were noted to light or deep palpation. The is palpable and is 7cm at the MCL and 1cm below the right costal margin. However, the spleen, right and left kidneys are not palpable.

GU: Palpate the suprapubic abdomen assessing pain and urine retention.

Extremities: Inspect the symmetry of extremities to assess ease of movement and areas of swelling and redness.

Musculoskeletal: Palpate over joints, noting areas of tenderness or warmth. Assess patient range of motion, noting crepitus and strength.

Neurological: Alert and oriented X3, follow commands, move all extremities. Assess the patient’s appearance, attention span, orientation and judgment.

Assessment: 

Based on the currently available data, assessment is:

  • The primary assessment is Community-acquired pneumonia. There is a productive and non-productive cough with sputum, which is occasionally blood-tinged, and shortness of breath which are the common signs of pneumonia. (Loscalzo,2016). In addition, the patient has a fever, continuous cough, crackles on auscultation, increased fremitus, and co-workers are also sick, strengthening the diagnosis of bacterial community-acquired pneumonia (Porter,2018). Treatment for this patient would include; rest and encourage fluids at least1 to two liters daily, Tessalon pearls 200mg PO tid prn for cough, guaifenesin 400mg PO q4h prn to loosen up secretions with plenty of water and empiric antibiotics.

Plan:

  • Assess the patient’s vital signs and address any abnormalities in breathing noted.
  • Address the patient’s hyperthermia and difficulty in breathing.
  • Order appropriate laboratories and imaging to arrive at a diagnosis and plan appropriate management.
  • Laboratories may include a complete blood count to assess infection, markers of inflammation such as CRP/ESR, serum electrolytes, APTT/INR since the patient had hemoptysis (Ghahramani, Tabrizi, Lankarani, et al., 2020)
  • A chest X-ray is the best initial assessment tool in diagnosing the patient. Note for any consolidations or infiltration seen in pneumonia, upper lobe concavities seen in tuberculosis, or masses seen in malignancies.
  • AFB smear to rule out tuberculosis (Caulfield & Wengenack, 2016).
  • Sputum culture to identify etiology if bacterial in origin to rule out any respiratory diseases.

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Soap Note Sample | Nursing Paper Writing Help Online . (2022, June 03). Essay Writing . Retrieved December 04, 2022, from https://www.essay-writing.com/samples/soap-note-sample-nursing-paper-writing-help-online/
“ Soap Note Sample | Nursing Paper Writing Help Online .” Essay Writing , 03 Jun. 2022, www.essay-writing.com/samples/soap-note-sample-nursing-paper-writing-help-online/
Soap Note Sample | Nursing Paper Writing Help Online . [online]. Available at: <https://www.essay-writing.com/samples/soap-note-sample-nursing-paper-writing-help-online/> [Accessed 04 Dec. 2022].
Soap Note Sample | Nursing Paper Writing Help Online [Internet]. Essay Writing . 2022 Jun 03 [cited 2022 Dec 04]. Available from: https://www.essay-writing.com/samples/soap-note-sample-nursing-paper-writing-help-online/
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