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1. What symptom caused the patient to seek medical help? 2. What was the patient's previous history? story}

1. What symptom caused the patient to seek medical help? 2. What was the patient's previous history? story}

Principles Of Pharmacology Med Assist
Principles Of Pharmacology Med Assist
6th Edition
ISBN:9781337512442
Author:RICE
Publisher:RICE
Chapter10: Medication Administration Essentials
Section: Chapter Questions
Problem 16RQ
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Respiratory System SOAP Note "Medical Terminology Systems" (2017). Gylys, Barbara and Wedding, Mary Ellen. FA Davis Date: February 1,20XX Patient: Flowers, Richard Chief Complaint: SOB Time registered: 1345 hours Physician: Samara Batichara, MD Emergency Department Record Medications: Vytorin 10/20 mg daily; Toprol-XL 50 mg daily; Azmacort 2 puffs three times a day; Proventil 2 puffs every 6 hours S: This 49 year old man with Hx of COPD is admitted because of exacerbation of SPB over the past few days. Patient was a heavy smoker and states that he quit smoking for a short time but now smokes 3-4 cigarettes day. He has a Hx of difficult breathing, hypertension, COPD, and peripheral vascular disease. The patient underwent triple bypass surgery in 19XX. O: T: 99.9 F. BP: 180/90. Pulse: 80 and regular. R: 20 and shallow. PE indicates scattered bilateral wheezes and rhonchi heard anteriorly and posteriorly. Compared with a portable chest film taken 22 months earlier, the current study most likely indicates interstitial vascular congestion. Some super imposed inflammatory change cannot be excluded. There may also be some pleural reactive change. A: 1. Acute exacerbation of chronic obstructive pulmonary disease. 2. Heart Failure 3. Hypertension 4. Peripheral vascular disease P: Admit to Hospital Answer the following questions using the SOAP Note 1. What symptom caused the patient to seek medical help? 2. What was the patient's previous history? istory?
Transcribed Image Text:Respiratory System SOAP Note "Medical Terminology Systems" (2017). Gylys, Barbara and Wedding, Mary Ellen. FA Davis Date: February 1,20XX Patient: Flowers, Richard Chief Complaint: SOB Time registered: 1345 hours Physician: Samara Batichara, MD Emergency Department Record Medications: Vytorin 10/20 mg daily; Toprol-XL 50 mg daily; Azmacort 2 puffs three times a day; Proventil 2 puffs every 6 hours S: This 49 year old man with Hx of COPD is admitted because of exacerbation of SPB over the past few days. Patient was a heavy smoker and states that he quit smoking for a short time but now smokes 3-4 cigarettes day. He has a Hx of difficult breathing, hypertension, COPD, and peripheral vascular disease. The patient underwent triple bypass surgery in 19XX. O: T: 99.9 F. BP: 180/90. Pulse: 80 and regular. R: 20 and shallow. PE indicates scattered bilateral wheezes and rhonchi heard anteriorly and posteriorly. Compared with a portable chest film taken 22 months earlier, the current study most likely indicates interstitial vascular congestion. Some super imposed inflammatory change cannot be excluded. There may also be some pleural reactive change. A: 1. Acute exacerbation of chronic obstructive pulmonary disease. 2. Heart Failure 3. Hypertension 4. Peripheral vascular disease P: Admit to Hospital Answer the following questions using the SOAP Note 1. What symptom caused the patient to seek medical help? 2. What was the patient's previous history? istory?
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