100% satisfaction guarantee Immediately available after payment Both online and in PDF No strings attached
logo-home
(SOAP NOTE) NR511 KATIE 65 YO FEMALE (CC Coughing worse at night, fatigue and gets winded daily while walking) $10.49
Add to cart

Exam (elaborations)

(SOAP NOTE) NR511 KATIE 65 YO FEMALE (CC Coughing worse at night, fatigue and gets winded daily while walking)

 9 views  0 purchase

(SOAP NOTE) NR511 KATIE 65 YO FEMALE (CC Coughing worse at night, fatigue and gets winded daily while walking)

Preview 1 out of 3  pages

  • November 26, 2023
  • 3
  • 2023/2024
  • Exam (elaborations)
  • Unknown
All documents for this subject (56)
avatar-seller
Dreamer001
(SOAP NOTE) NR511 KATIE 65 YO FEMALE (CC Coughing worse at
night, fatigue and gets winded daily while waking up)

Patient Information: Katie, 65yr, female S:
CC: Patient states “I began coughing 1 week ago and its worse at night. My chest is starting to hurt from all
of the coughing”. She also is c/o fatigue and getting “winded” while walking daily and no energy to attend
her exercise classes.
HPI:
O: 1 week
L: Chest
D: 1 week (Have you had these symptoms in the past? If so, what months or seasons?)
C: Fatigue, winded, pain in chest (Is your cough dry or productive? Can you describe what the cough sounds
like? If your cough is productive, what color is your sputum? Have you noticed any blood in your sputum?
Besides your chest hurting, does anything else hurt (throat, sinuses, and ears)? Any chills, body aches, night
sweats? Do you hear any wheezing in your chest? Have you felt nauseous, any vomiting or diarrhea? Have
you noticed any swelling in your ankles or feet?)
A: walking, exercising, worse at night (Does anything else make your cough worse? Eating, drinking?)
R: none reported (Does anything relieve the cough?)
T: none reported (Have you taken anything for your cough?)
S: Severe, affected her daily activities, and sleep. (Can you rate the pain from 0 to 10? Are these symptoms
changing your ability to do your normal activities?)
Current Medications: Multivitamin, Evista 60 mg daily, HCTZ 25 mg daily
Allergies: Demerol, pollen
PMHx: Chicken pox, measles and rubella during childhood. Osteopenia, HTN, and hyperlipidemia.
Surgical Hx: Tonsillectomy and cholecystectomy. Hospitalized for childbirth and surgeries
Social Hx: Lives with husband John, and married daughter and her family. She watches her grandkids when
Mary and her husband are at work. Her husband and son-in-law smoke, but not in the house. She does not
smoke or drink alcohol.

ROS:

CONSTITUTIONAL: Reports fatigue. Denies weight loss, fever, and chills. She did not check her
temperature.
HEENT: Head - No headache, dizziness, or syncope. Eyes – no visual loss, blurred vision, or double vision.
Ears – no hearing loss, no ear discharge, or swelling. Nose – no sneezing, congestion, or runny nose. Throat
- no report of sore throat, or difficulty swallowing.

CARDIOVASCULAR: Reports chest pain. No palpitations or edema.

RESPIRATORY: Reports cough and shortness of breath.

GASTROINTESTIONAL: No anorexia, nausea, vomiting or diarrhea. No abdominal pain or blood in
stool.

GENITOURINARY: N/A

NEUROLIGICAL: No headache or dizziness
1|Page

The benefits of buying summaries with Stuvia:

Guaranteed quality through customer reviews

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

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

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 Dreamer001. Stuvia facilitates payment to the seller.

Will I be stuck with a subscription?

No, you only buy these notes for $10.49. You're not tied to anything after your purchase.

Can Stuvia be trusted?

4.6 stars on Google & Trustpilot (+1000 reviews)

52510 documents were sold in the last 30 days

Founded in 2010, the go-to place to buy study notes for 14 years now

Start selling
$10.49
  • (0)
Add to cart
Added