Mr week 3 soap | Nursing homework help

*Subjective:

CC:

HPI: Mrs B is a 64 y/o Caucasian female patient that presents with a cough over the last 4 weeks

that is moderate in severity. She initially presented to the walk-in clinic last week and was

diagnosed with an upper respiratory infection and was prescribed azithromycin. Mrs. B feels that

the antibiotic was not helpful and she has not been sleeping well due to the congestion and

cough. She denies nasal discharge but is coughing up clear/white phlem. She reports feeling like

she cannot get the mucous out of her chest and feels SOB at times. She denies any body aches,

fever, chills, chest pain or poor oral intake.

PMH: PMH includes

Osteopenia (2019), Depressive disorder (1980), hypertension (2016), COPD (2016),

hyperlipidemia (2018), type II DM (2018), morbid obesity (2018), Hospitalized (9/2018) for 7

days with pneumonia,

Surgery history: Left femur fracture (2018), Hysterectomy- age 45, Appendectomy- age 30,

Colonoscopy (2015), Coronary Artery Bypass (CABG) – x5 (2016), Dilation & curettage,

Hemorrhoidectomy (2012), Tubal ligation- age 35

Allergies: Keflex- angioedema, Metformin- diarrhea, Quinine- angioedema, Ultram-

angioedema

Medications:

albuterol sulfate HFA 90 mcg/actuation aerosol inhaler. Inhale 2 puff(s) every 4 hours by

inhalation route.

benzonatate 200 mg po TID PRN

Breo Ellipta 100 mcg-25 mcg/dose powder 1 inhalation every day

Duloxetine 20mg po daily

Finofibrate 160mg po daily

glipiZIDE ER 10 mg tablet po daily

HCTZ 25mg po daily

Rosuvastatin 10mg po daily

Lisinopril 10mg po daily

Metoprolol tartate 25 mg po daily

Social History: Mrs. B is a retired factory worker and has lived in Florida for 3 years. She

currently smokes ½ pack of cigarettes for 20 years. Drinks 1-2 beers per week. She is widowed

since 2002 husband passed from complications of Emphysema. She has two adult daughters

living at home. Her grandchildren live with their father who has sole custody. Mrs. B owns a

home which is paid for. Daughter Brenda has two jobs. Her son in law also lives in the home he

works. All family members smoke in the house. She has four dogs, 10 outdoor cats, and 5 birds

living in the garage.

Family History: Father died of MI age 60

Mother- colon cancer and died at age 70

Health Maintenance/Promotion: Up to date on immunizations, flu (10/2018), pneumonia

(1/2018 & 11/18). Colonoscopy and Mammogram up to date (12/2018). Diet- Diabetic. She

occasionally exercises by walking.

ROS:

General: Feeling tired, usual weight, and below her baseline of health.

Skin: Denies skin or hair changes

HEENT: Denies headache or injury. Denies vision changes, redness, earaches, or hearing

changes. Denies nasal discharge. Sore throat at times from coughing. No muscle aches, itching or

sinus trouble.

Respiratory: Productive cough with phlegm that is white/clear. C/o SOB. Last CXR 2019

Cardiovascular: Denies chest pain, dyspnea, orthopnea, or palpitations. Denies rheumatic fever,

heart murmur. Pertinent for hypertension. Last BP taken this visit.

*Objective:

PE:

Gen: Well developed female in no apparent distress. She is cooperative and pleasant. Hair is

well groomed.

VS: BP 126/78 HR 76 O2 sat 96% on RA RR 20 T 97.9 Height 60 inches Weight 178 LBs BMI

34.8

/Skin: Dry, intact. No rashes or erythema noted.

HEENT: Head without lesions. Hair texture average. Conjunctiva clear without discharge. Ear

canals clear, tympanic membrane pearly grey without redness. Hearing grossly intact. Nose

without external lesions and mucosa not inflamed. Throat and oral pharynx with mild erythema.

Dentures in place, well-fitting without tenderness or abscess noted. No exudate or lesions. No

Frontal and maxillary sinus tender to palpation. No lymphadenopathy.

Lungs: Chest wall expansion shallow but symmetrical. No use of accessory muscles or SOB

noted. Lung sounds with wheezing and rhonchi throughout.

CV: Chest symmetrical. Rate regular. Normal S1 and S2. No carotid bruit. No JVD. No digital

clubbing noted. No cyanosis. No murmurs noted.

Diagnostic Tests: Chest X-ray- mild chronic bronchitis

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