Assignment: Tina Jones Respiratory Assessment SOAP NOTE

Sample Answer for Assignment: Tina Jones Respiratory Assessment SOAP NOTE Included After Question

Medication: No known drug allergy
Food: No known food allergy
Environment: Dust, cats
History of Present Illness (HPI)
Chief Complaint (CC) Shortness of breath and wheezing.
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 Two days ago.

Location Respiratory system.

Duration Five minutes

Characteristics Moderate wheezing and severe shortness of breath.

Aggravating Factors Lying flat and movement.

Relieving Factors Albuterol inhaler

Treatment Albuterol inhaler Assignment Tina Jones Respiratory Assessment SOAP NOTE

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
Albuterol inhaler
90 mcg- 2 puffs Q4H
PRN
25 Years
To relieve wheezing and shortness of breath.
Tylenol
500 mg TID
PRN
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Alleviate headache
Advil
200 mg
PRN
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Relieve cramps
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Caroline has a believe that she has actually put on weight and that might have
worsened the stretchmarks.
Medications:
Patient is on the following medications;
Pregnacare which contains mostly vitamins
400 μg of folic acid prescribed once daily
Iron 600mg Daily
Metformin 500mg twice daily for diabetes
Norvasc 10mg daily for hypertension

Allergies: Allergic to Sulphur medications. No known food allergies.

Past Medical History (PMH): Ms Craoline is a known Type 2 diabetic patient, was last
hospitalized in 2020 prior to her recent pregnancy on account of uncontrolled
hyperglycemia which was managed and well controlled during the 2 days’ hospitalization
before being discharged, patient also has history of borderline hypertension.

Past Surgical History (PSH): Patient denies any surgical history.

Sexual/Reproductive History: Ms. Caroline is Straight and is sexually active. No
positive history of sexual abuse, has had 2 partners since she became sexually active.
Menarche started at the age of 12 and since then have always had a regular menstrual
cycle of 28days.

Past Medical History (PMHx) – Includes but not limited to immunization status (note date of last tetanus for all adults), past major illnesses, hospitalizations, and surgeries. Depending on the CC, more info may be needed.

Diagnosed with asthma at the age of 2 ½ years. She has been admitted five times due to asthma attacks with the recent admission being at 16 years. She denies using spirometry, peak flow, home nebulizer or vaporizer. She has no history of intubation and has no pulmonologist or allergist.
Social History (Soc Hx) – Includes but not limited to occupation and major hobbies, family status, tobacco and alcohol use, and any other pertinent data. Include health promotion such as use seat belts all the time or working smoke detectors in the house.

She denies current use of tobacco, alcohol, and illicit drugs. She admits to smoking marijuana for 5 or 6 years,and her last use was at age 21 years. She admits that she does not exercise. She is not aware of any environmental exposures or irritants at her job or home. She changes her sheets weekly and denies dust/mildew at her home. She uses a hypoallergenic pillow cover and her mattress is one year old.

Family History (Fam Hx) – Includes but not limited to illnesses with possible genetic predisposition, contagious or chronic illnesses. Reason for death of any deceased first degree relatives should be included. Include parents, grandparents, siblings, and children. Include grandchildren if pertinent.

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Younger sister has a history of asthma. No family history of eczema, chronic nasal or sinus problems.

Review of Systems (ROS): Address all body systems that may help rule in or out a differential diagnosis Check the box next to each positive symptom and provide additional details.
Constitutional Skin HEENT
☐Fatigue Reports low enery levels
☒Weakness Click or tap here to enter text.
☒Fever/Chills Click or tap here to enter text.
☒Weight Gain Click or tap here to enter text.
☒Weight Loss Click or tap here to enter text.
☐Trouble Sleeping Has nocturnal shortness of breath.
☒Night Sweats Click or tap here to enter text.
☒Other:
Click or tap here to enter text.
☒Itching Click or tap here to enter text.
☒Rashes Click or tap here to enter text.
☒Nail Changes Click or tap here to enter text.
☒Skin Color Changes Click or tap here to enter text.
☒Other:
Click or tap here to enter text.
☒Diplopia Click or tap here to enter text.
☒Eye Pain Click or tap here to enter text.
☒Eye redness Click or tap here to enter text.
☒Vision changes Click or tap here to enter text.
☒Photophobia Click or tap here to enter text.
☒Eye discharge Click or tap here to enter text.
☒Earache Click or tap here to enter text.
☒Tinnitus Click or tap here to enter text.
☒Epistaxis Click or tap here to enter text.
☒Vertigo Click or tap here to enter text.
☒Hearing Changes Click or tap here to enter text.
☒Hoarseness Click or tap here to enter text.
☒Oral Ulcers Click or tap here to enter text.
☒Sore Throat Click or tap here to enter text.
☒Congestion Click or tap here to enter text.
☒Rhinorrhea Click or tap here to enter text.
☒Other:
Click or tap here to enter text.

Respiratory Neuro Cardiovascular
☐Cough non-productive
☒Hemoptysis Click or tap here to enter text.
☐Dyspnea Complains of shotnee of breath every 4 hours
☐Wheezing Reports 10 episodes of wheezing
☒Pain on Inspiration Click or tap here to enter text.
☒Sputum Production
Choose an item.
Choose an item.
Choose an item.
☐Other: History of asthma

☒Syncope or Lightheadedness Click or tap here to enter text.
☒Headache Click or tap here to enter text.
☒Numbness Click or tap here to enter text.
☒Tingling Click or tap here to enter text.
☒Sensation Changes
Choose an item.
☒Speech Deficits Click or tap here to enter text.
☒Other: Click or tap here to enter text.
☒Chest pain Click or tap here to enter text.
☐SOB Every 4 hours
☐Exercise Intolerance Does not exercise
☐Orthopnea Lying flat triggers exarcerbation of symptoms.
☒Edema Click or tap here to enter text.
☒Murmurs Click or tap here to enter text.
☒Palpitations Click or tap here to enter text.
☒Faintness Click or tap here to enter text.
☒OC Changes Click or tap here to enter text.
☒Claudications Click or tap here to enter text.
☒PND Click or tap here to enter text.
☒Other: Click or tap here to enter text.

MSK
GI GU PSYCH
☒Pain Click or tap here to enter text.
☒Stiffness Click or tap here to enter text.
☒Crepitus Click or tap here to enter text.
☒Swelling Click or tap here to enter text.
☒Limited ROM Choose an item.
☒Redness Click or tap here to enter text.
☒Misalignment Click or tap here to enter text.
☒Other: Click or tap here to enter text.
☒Nausea/Vomiting Click or tap here to enter text.
☒Dysphasia Click or tap here to enter text.
☒Diarrhea Click or tap here to enter text.
☒Appetite Change Click or tap here to enter text.
☒Heartburn Click or tap here to enter text.
☒Blood in Stool Click or tap here to enter text.
☒Abdominal Pain Click or tap here to enter text.
☒Excessive Flatus Click or tap here to enter text.
☒Food Intolerance Click or tap here to enter text.
☒Rectal Bleeding Click or tap here to enter text.
☒Other:
Click or tap here to enter text.
☒Urgency Click or tap here to enter text.
☒Dysuria Click or tap here to enter text.
☒Burning Click or tap here to enter text.
☒Hematuria Click or tap here to enter text.
☒Polyuria Click or tap here to enter text.
☒Nocturia Click or tap here to enter text.
☒Incontinence Click or tap here to enter text.
☒Other: Click or tap here to enter text.
☒Stress Click or tap here to enter text.
☒Anxiety Click or tap here to enter text.
☒Depression Click or tap here to enter text.
☒Suicidal/Homicidal Ideation Click or tap here to enter text.
☒Memory Deficits Click or tap here to enter text.
☒Mood Changes Click or tap here to enter text.
☒Trouble Concentrating Click or tap here to enter text.
☒Other: Click or tap here to enter text.
GYN
☒Rash Click or tap here to enter text.
☒Discharge Click or tap here to enter text.
☒Itching Click or tap here to enter text.
☒Irregular Menses Click or tap here to enter text.
☒Dysmenorrhea Click or tap here to enter text.
☒Foul Odor Click or tap here to enter text.
☒Amenorrhea Click or tap here to enter text.
☒LMP: Click or tap here to enter text.
☒Contraception Click or tap here to enter text.
☒Other:Click or tap here to enter text.

Body System Positive Findings
Negative Findings
General
Choose an item.