Case
TINA JONES RESPIRATORY WEEK 2 SHADOWHEALTH(DETAILED FOR SUCCESS)(GRADED A+)
- Course
- Institution
TINA JONES RESPIRATORY WEEK 2 SHADOWHEALTH(DETAILED FOR SUCCESS)(GRADED A+)
[Show more]
Seller
Follow
GRADEGURU
Reviews received
Content preview
Ti na j ones re spi ra toryweek2
TINA JONES
RESPIRATORY
WEEK 2
TINA JONES
RESPIRATORY
WEEK 2
, SOAP Note Template
S: Subjective
Information the patient or patient representative told you
Initials: TJ 5674 w 1st ave Spinghill Fl Age: 28 Gender: female
34606
Height Weight BP HR RR Temp SPO2 Pain Allergies
170 89 kg 140/ 89 20 98.5 97% Medication: Penicillin
cm 81 Food: Na
Environment: Cats
History of Present Illness (HPI)
Chief Complaint (CC) Chest tightness, shortness of breath, wheezing, hacky cough, fatigue CC is a BRIEF statement identifying
Onset 2 days ago why the patient is here - in the
Location Chest and lungs patient’s own words - for instance
"headache", NOT "bad headache for 3
Duration 2 days days”. Sometimes a patient has more
Characteristics Tightness in chest with shortness of breath, dry hacky cough than one complaint. For example: If
the patient presents with cough and
Aggravating Factors Allergies to cats sore throat, identify which is the CC
Relieving Factors Proventil inhaler with some relief and which may be an associated
Treatment Patient has been using an inhaler every 4 hours with very little relief symptom
Current Medications: Include dosage, frequency, length of time used and reason for use; also include OTC or homeopathic products.
Medication Length of Time
(Rx, OTC, or Homeopathic)
Dosage Frequency Used Reason for Use
Proventil 90 mcg 2 puffs Q 4-6 hrs prn Since 2.5 years Asthma
old
Tylenol 500 mg 1-2 tabs Every 6 hrs undetermined Head aches and body pain
Ibuprofen 200 mg 1-2 tab Q6 hrs undetermined Cramps body aches
The benefits of buying summaries with Stuvia:
Guaranteed quality through customer reviews
Stuvia customers have reviewed more than 700,000 summaries. This how you know that you are buying the best documents.
Quick and easy check-out
You can quickly pay through credit card or Stuvia-credit for the summaries. There is no membership needed.
Focus on what matters
Your fellow students write the study notes themselves, which is why the documents are always reliable and up-to-date. This ensures you quickly get to the core!
Frequently asked questions
What do I get when I buy this document?
You get a PDF, available immediately after your purchase. The purchased document is accessible anytime, anywhere and indefinitely through your profile.
Satisfaction guarantee: how does it work?
Our satisfaction guarantee ensures that you always find a study document that suits you well. You fill out a form, and our customer service team takes care of the rest.
Who am I buying these notes from?
Stuvia is a marketplace, so you are not buying this document from us, but from seller GRADEGURU. Stuvia facilitates payment to the seller.
Will I be stuck with a subscription?
No, you only buy these notes for $9.09. You're not tied to anything after your purchase.
Can Stuvia be trusted?
4.6 stars on Google & Trustpilot (+1000 reviews)
76799 documents were sold in the last 30 days
Founded in 2010, the go-to place to buy study notes for 14 years now