No bleeding tendency Thesis

 

 

Running head: BENCHMARK: ACADEMIC CLINICAL SOAP NOTE 1

Benchmark Academic Clinical Soap Note

Grand Canyon University

ANP 652

February 05, 2020

Admission Date: 12-03-2019

Chief Complaint:

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2 BENCHMARK: ACADEMIC CLINICAL SOAP NOTE

Patient c/o worsening SOB since this morning.

Background:

This is a pleasant 33-year-old obese Hispanic male who presents to emergency room

and does not go and see any doctor, comes in with some shortness of breath and cough. Pa-

tient notes that he has been having shortness of breath with productive cough for a few days.

Patient states his wife also notes he has been wheezy however denies any history of COPD,

asthma or smoking. Patient does note he works in construction and dry wall however does

use respirator. Nothing has made symptoms better. Symptoms were worse after walking and

shower at home. No eliciting factors have been noted. Symptoms are moderate to severe. Pa-

tient does have some productive sputum and intermittent wheezing. Denies any history of

COPD, asthma, similar illness. Denies any smoking. Denies any hemoptysis. Patient does

note he works in construction and dry wall however does use respirator.

Hospital Medications:

❖ acetaminophen, 650 mg= 2 TAB, PO, Q4H (Every 4 hours), PRN

❖ Albuterol NEB, 2.5 mg= 3 mL, NEB, TID (3 times a day)

❖ Albuterol NEB, 2.5 mg= 3 mL, NEB, Q2H (Every 2 hours), PRN

❖ cefTRIAXone 2 g IV Push, Q24 (Every 24 hours)

❖ montelukast, 10 mg= 1 TAB, PO, QHS (At bedtime)

❖ nitroglycerin, 0.4 mg= 1 TAB, Sublingual, 5MX3 (Every 5 minutes x 3 doses), PRN

❖ ondansetron, 4 mg= 2 mL, IV Push, Q4H (Every 4 hours), PRN

❖ Saline Flush, 10 mL, IV Push, Q12H (Every 12 hours)

❖ Zithromax, 500 mg= 2 TAB, PO, Q24H (Every 24 hours) Review of Systems:

Constitutional: No fever, no chills, no sweats, no weakness.

Eye: No recent visual problem, icterus, discharge, blurring, double vision.

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3 BENCHMARK: ACADEMIC CLINICAL SOAP NOTE

Ear/Nose/Mouth/Throat: No decreased hearing, ear pain, nasal congestion, sore throat.

Respiratory: Dyspnea, + wheezing.

Cardiovascular: Chest pain with coughing.

Gastrointestinal: Denies nausea or vomiting

Genitourinary: No dysuria, hematuria, or pain.

Hematological/Lymphatics: No bleeding tendency, swollen lymph glands

Endocrine: No excessive thirst, polyuria, cold intolerance, heat intolerance, excessive

hunger.

Immunologic: No recurrent fevers, recurrent infections, malaise

Musculoskeletal: No back pain or trauma.

Integumentary: No Rash, pruritus, abrasions, breakdown, burns, petechiae, skin lesion.

Neurologic: No headache, dizziness, numbness, weakness. Alert and oriented X4.

Psychiatric: No sleeping problems, irritability, or mood swings/depression.

All other systems are negative

Vital Signs:

T: 98.7 F TMIN: 98.7 F TMAX: 98.9 F HR: 126 RR: 22 BP: 167/77 SpO2:

96% WT: 105 kg BMI: 36.33

Physical Examination:

General: Well nourished, alert, cooperative, moderate discomfort.

HEENT: Normocephalic, oral mucosa is moist, normal sclera, no JVD.

Respiratory: Mild wheezes bilaterally, prolonged expiration , respirations non-labored. Car-

diovascular: Tachycardic, borderline hypoxemia

Gastrointestinal: Soft, no guarding, present bowel sounds, no tenderness.

Integumentary: Warm, no rash, skin turgor not decreased.

Musculoskeletal: Normal range of motion, no deformity.

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