Soap Note Respiratory TinaJones

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SOAP NOTES TEMPLATE Location: Chest and Lungs Duration: Two days ago. Experiencing episodes lasting several minutes every 4 hours since original episode. Waking up twice a night with asthma the pa... st 2 nights. Characteristics: Shortness of breath not relieve by inhaler prescribed use; Wheezing, inability to lie flat, dry nonproductive cough; waking at night due to shortness of breath; asthma interferes with activities of daily life. Chest tightness, not pain. Aggravating Factors: Exposure to cats or dust; Burst of physical exertions “when hurrying up or walking upstairs”. Relieving Factors: Usually inhaler, nothing currently Treatment: Proventil 90mcg inhaler 3 puffs every 4 hours Current Medications Medication Dosage Frequency Length of Time Used Reason for Use Proventil 90mcg 3 puffs every 4 hours PRN 25.5 years Asthma: Wheezing, Shortness of breath; Cats Tylenol Gel Caps ES 500mg 1 capsule PRN < few weeks ago Headache Advil 200mg 3 tablets Three Times a day PRN Menstrual Cramps Metformin Unknown 1 tablet BID 1 year age 24 Type 2 Diabetes Past Medical History (PMHx) – Asthma: Diagnosed age 2.5 years Diabetes: Diagnosed age 24 years. Has not taken medications for diabetes for 3 years. Manages diabetes by avoiding sugar and trying to stay active. Foot Wound: A few months ago, states it is healing Hospitalizations: State” A bunch of times as a child for asthma”; last hospitalization was age 16 years. Chest X-ray age 16 years X-ray foot few months ago Surgery: Denies [Show More]

Last updated: 1 year ago

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