SOAP 5 - Nursing homework help
SOAP Note Case , I uploaded an example, you can create your own case, with a person older than 21 years. Including patient name initials , date of birth and all the examples of personal and medical history provided in the example. I need all the information wrote  in the example, No require references, due for Monday October 5.SOAP NOTE: Asthma Exacerbation 3 Patient name: A.A Sex: Female DOB: 9/04/1995 Age: 25 years-old Ethnicity: Hispanic. Language: Spanish. Marital Status: Married Religion: Christian SUBJECTIVE: Chief Complaint: “I can’t cash my breath since this morning when I finished my exercise routine at gym” History of Present Illness:  Patient is a 25-years-old that presents to the office with a chief complain of Shortness of breath, since this morning after finished workout at gym, patient with wheezing upon auscultation. Patient denied any other symptoms related. Past Medical History:   Surgeries: N/A ( if any add it) Hospitalizations: N/A if any add it Chronic Medical conditions: Asthma as per records and patient statement. Psychiatric Illnesses: None. Injuries: None Childhood Illnesses: Asthma since 5 years old. Preventive Care: Pap smear: 12/2019( Negative) Family History:  Mother is alive: Asthma Father is alive: Cancer and Diabetes. Sister is alive: Diabetes Brother: No brother Children: No Children Additional History: Immunizations: All vaccines current/ Flu vaccine: 9/15/2020 Nutritional Status: Regular Diet. Physical Trauma/ Accident: Denied BEHAVIOR/HABIT: Caffeine: Yes Smoke: No Alcohol:No Drug: No using illicit drugs Exercises: Moderate exercise habit Legal Document: Patient does not have a living will and livings will/advanced not directives on records. FUNCTIONAL STATUS: Normal/ Independent ADL’s. Allergies: Not Known Drug Allergies. Or what the patient has. Medications:  currently taking: Albuterol 2.5 mg 3 or 4 times a day by nebulization, over approximately 5 to 15 minutes. Advair Diskus 2 puff twice a day. HEALTH CARE MAINTENANCE: She has received the influenza vaccine recently. Annual check up with primary care provider. Review of physical health, well being, and psychosocial concerns, nutritional education and guidance, and health education, guidance annually by patient chart. OBJECTIVE: APPEARANCE: Well nourished, developed and dressed/groomed, pleasant demeanor, speech clear. Appears to be without discomfort, does not look distressed. VITALS SIGNS: -Blood Pressure: 100/58  -Pulse: 99 bpm -Respiration: 24 rpm ) Not Regular) -Temperature: 98.3 degrees Fahrenheit -O2 saturation: 100\% at room air. -Weight: 130 lbs -Height: 5’2” -BMI: 22 -Pain level 0/10 on scale of pain. (If is a case with pain put scale from 0-10 and describe it) OLDCART Onset-Location-Duration-Characteristics-Aggravating-Factors-Relieving-FactoTreatment. Respiratory: Shortness of breath, with rapid respiration, on auscultation wheezing through all ASSESSMENT: DIAGNOSIS: Asthma exacerbation diagnosis due clinical presentation and physical exam. 1. Asthma exacerbation (ICD 10: J45.901). Asthma is a disease of diffuse airway inflammation caused by a variety of triggering stimuli resulting in partially or completely reversible bro
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