Loading...

Messages

Proposals

Stuck in your homework and missing deadline? Get urgent help in $10/Page with 24 hours deadline

Get Urgent Writing Help In Your Essays, Assignments, Homeworks, Dissertation, Thesis Or Coursework & Achieve A+ Grades.

Privacy Guaranteed - 100% Plagiarism Free Writing - Free Turnitin Report - Professional And Experienced Writers - 24/7 Online Support

Soap note for shortness of breath

18/03/2021 Client: saad24vbs Deadline: 2 Day

Name: Mr. W.S.

Age: 65-year-old

Sex: Male

Source: Patient

Allergies: None

Current Medications: Atorvastatin tab 20 mg, 1-tab PO at bedtime

PMH: Hypercholesterolemia

Immunizations: Influenza last 2018-year, tetanus, and hepatitis A and B 4 years ago.

Surgical History: Appendectomy 47 years ago.

Family History: Father- died 81 does not report information

Mother-alive, 88 years old, Diabetes Mellitus, HTN

Daughter-alive, 34 years old, healthy

Social Hx: No smoking history or illicit drug use, occasional alcoholic beverage consumption on social celebrations. Retired, widow, he lives alone.

SUBJECTIVE:

Chief complain: “headaches” that started two weeks ago

Symptom analysis/HPI:

The patient is 65 years old male who complaining of episodes of headaches and on 3 different occasions blood pressure was measured, which was high (159/100, 158/98 and 160/100 respectively). Patient noticed the problem started two weeks ago and sometimes it is accompanied by dizziness. He states that he has been under stress in his workplace for the last month.

Patient denies chest pain, palpitation, shortness of breath, nausea or vomiting.

ROS:

CONSTITUTIONAL: Denies fever or chills. Denies weakness or weight loss. NEUROLOGIC: Headache and dizzeness as describe above. Denies changes in LOC. Denies history of tremors or seizures.

HEENT: HEAD: Denies any head injury, or change in LOC. Eyes: Denies any changes in vision, diplopia or blurred vision. Ear: Denies pain in the ears. Denies loss of hearing or drainage. Nose: Denies nasal drainage, congestion. THROAT: Denies throat or neck pain, hoarseness, difficulty swallowing.

Respiratory: Patient denies shortness of breath, cough or hemoptysis.

Cardiovascular: No chest pain, tachycardia. No orthopnea or paroxysmal nocturnal

dyspnea.

Gastrointestinal: Denies abdominal pain or discomfort. Denies flatulence, nausea, vomiting or

diarrhea.

Genitourinary: Denies hematuria, dysuria or change in urinary frequency. Denies difficulty starting/stopping stream of urine or incontinence.

MUSCULOSKELETAL: Denies falls or pain. Denies hearing a clicking or snapping sound.

Skin: No change of coloration such as cyanosis or jaundice, no rashes or pruritus.

Objective Data

CONSTITUTIONAL: Vital signs: Temperature: 98.5 °F, Pulse: 87, BP: 159/92 mmhg, RR 20, PO2-98% on room air, Ht- 6’4”, Wt 200 lb, BMI 25. Report pain 0/10.

General appearance: The patient is alert and oriented x 3. No acute distress noted. NEUROLOGIC: Alert, CNII-XII grossly intact, oriented to person, place, and time. Sensation intact to bilateral upper and lower extremities. Bilateral UE/LE strength 5/5.

HEENT: Head: Normocephalic, atraumatic, symmetric, non-tender. Maxillary sinuses no tenderness. Eyes: No conjunctival injection, no icterus, visual acuity and extraocular eye movements intact. No nystagmus noted. Ears: Bilateral canals patent without erythema, edema, or exudate. Bilateral tympanic membranes intact, pearly gray with sharp cone of light. Maxillary sinuses no tenderness. Nasal mucosa moist without bleeding. Oral mucosa moist without lesions,.Lids non-remarkable and appropriate for race.

Neck: supple without cervical lymphadenopathy, no jugular vein distention, no thyroid swelling or masses.

Cardiovascular: S1S2, regular rate and rhythm, no murmur or gallop noted. Capillary refill < 2 sec.

Respiratory: No dyspnea or use of accessory muscles observed. No egophony, whispered pectoriloquy or tactile fremitus on palpation. Breath sounds presents and clear bilaterally on auscultation.

Gastrointestinal: No mass or hernia observed. Upon auscultation, bowel sounds present in all four quadrants, no bruits over renal and aorta arteries. Abdomen soft non-tender, no guarding, no rebound no distention or organomegaly noted on palpation

Musculoskeletal: No pain to palpation. Active and passive ROM within normal limits, no stiffness.

Integumentary: intact, no lesions or rashes, no cyanosis or jaundice.

Assessment

Essential (Primary) Hypertension (ICD10 I10): Given the symptoms and high blood pressure (156/92 mmhg), classified as stage 2. Once the organic cause of hypertension has been ruled out, such as renal, adrenal or thyroid, this diagnosis is confirmed.

Differential diagnosis:

· Renal artery stenosis (ICD10 I70.1)

· Chronic kidney disease (ICD10 I12.9)

· Hyperthyroidism (ICD10 E05.90)

Plan

Diagnosis is based on the clinical evaluation through history, physical examination, and routine laboratory tests to assess risk factors, reveal identifiable causes and detect target-organ damage, including evidence of cardiovascular disease.

These basic laboratory tests are:

· CMP

· Complete blood count

· Lipid profile

· Thyroid-stimulating hormone

· Urinalysis

· Electrocardiogram

Homework is Completed By:

Writer Writer Name Amount Client Comments & Rating
Instant Homework Helper

ONLINE

Instant Homework Helper

$36

She helped me in last minute in a very reasonable price. She is a lifesaver, I got A+ grade in my homework, I will surely hire her again for my next assignments, Thumbs Up!

Order & Get This Solution Within 3 Hours in $25/Page

Custom Original Solution And Get A+ Grades

  • 100% Plagiarism Free
  • Proper APA/MLA/Harvard Referencing
  • Delivery in 3 Hours After Placing Order
  • Free Turnitin Report
  • Unlimited Revisions
  • Privacy Guaranteed

Order & Get This Solution Within 6 Hours in $20/Page

Custom Original Solution And Get A+ Grades

  • 100% Plagiarism Free
  • Proper APA/MLA/Harvard Referencing
  • Delivery in 6 Hours After Placing Order
  • Free Turnitin Report
  • Unlimited Revisions
  • Privacy Guaranteed

Order & Get This Solution Within 12 Hours in $15/Page

Custom Original Solution And Get A+ Grades

  • 100% Plagiarism Free
  • Proper APA/MLA/Harvard Referencing
  • Delivery in 12 Hours After Placing Order
  • Free Turnitin Report
  • Unlimited Revisions
  • Privacy Guaranteed

6 writers have sent their proposals to do this homework:

Instant Homework Helper
University Coursework Help
Instant Assignments
WRITING LAND
Smart Homework Helper
Assignment Hub
Writer Writer Name Offer Chat
Instant Homework Helper

ONLINE

Instant Homework Helper

Hello, I an ranked top 10 freelancers in academic and contents writing. I can write and updated your personal statement with great quality and free of plagiarism

$25 Chat With Writer
University Coursework Help

ONLINE

University Coursework Help

You can award me any time as I am ready to start your project curiously. Waiting for your positive response. Thank you!

$60 Chat With Writer
Instant Assignments

ONLINE

Instant Assignments

You can award me any time as I am ready to start your project curiously. Waiting for your positive response. Thank you!

$174 Chat With Writer
WRITING LAND

ONLINE

WRITING LAND

I have read your project details. I can do this within your deadline.

$80 Chat With Writer
Smart Homework Helper

ONLINE

Smart Homework Helper

I am known as Unrivaled Quality, Written to Standard, providing Plagiarism-free woork, and Always on Time

$27 Chat With Writer
Assignment Hub

ONLINE

Assignment Hub

I will cover all the points which you have mentioned in your project details.

$80 Chat With Writer

Let our expert academic writers to help you in achieving a+ grades in your homework, assignment, quiz or exam.

Similar Homework Questions

3 heavenly bodies that were discovered using radio waves - Dibenzalacetone density - Otn multiplexing and mapping structure - A raisin in the sun full text - Entire classes work - Is it hard to find quality patches? - Michigan Alcoholism Screening - 2 minus twice a number - G1.2 - Havelock's six step change model - Nhs scotland bank staff - Final building inspection checklist - Wave on a string answer key - Reference circle in shm - Sainsbury's petrol station strathaven - Discussion: Reflection - Periodic inventory by three methods example - Agile release train uses which type of teams - Presentation - Management - Traditional and contemporary management strategies - Computer Crime - Rationing function of prices - U.S History - Marketing quiz - Romeo and juliet guided reading questions answer key - You are cordially invited to attend a dinner - Discussion AV - Discussion Question - To kill a mockingbird characters - Queensland kindergarten learning outcomes - Westminster leaving care team - Bond energy of f2 - Protection of Human Subjects in Research - How to make green eggs and ham prop - Cssa trial timetable 2021 - Www qualitycheck org consumer searchqcr aspx - 2015 ancient history hsc - Business - What are the keys on a glockenspiel made of - Westerville company reported the following results from last year's operations - Guigemar marie de france summary - Whitley county consolidated schools - A worn path annotations - Sae oil viscosity temperature chart - Create risk management plan b - What methods of capital acquisition did honest tea employ why - Why is protein the last resort for energy - Web server hardware and software chapter 8 - The monkey's paw pdf middle school - Why does ice float in water - Billing for laboratory services - How to print double sided on word - Money Paper - Week 4 Discussion - Opening a sonic franchise - Thermo king code 25 repair - Differentiate ln 1 x - Examples of comparison essay thesis statements - The adjusted trial balance for rowdy profits corporation - How to build a design team - Gcse computer science 8520 1 mark scheme - The death of the hired man summary and analysis - PROJECT - Field of view microscope - Elimination of unrealized profit on intercompany sales of inventory - Corporate social responsibility is mainly concerned with how a company affects the ________. - Lesson 54 sorry charlie charles law worksheet answers - How to program 8051 microcontroller in assembly language - Minimum password length packet tracer - Board of directors confidentiality agreement - Copenhagen 2025 climate plan - My brother sam is dead questions - Traffic jam group activity - Julian of norwich revelations of divine love sparknotes - A.1 risk management - His 100 multimedia presentation planning worksheet - Heritage dolls inc - 2014 hsc ext 1 - Doosan portable power manuals - Los vendidos analysis - Languages unsw edu au - Regents park public school - Job applicant rejection letter - Agree to time frames for carrying out workplace instructions - 3820 #5&6 - Prepare a balance sheet at june 30 2017 - Listen mr oxford don analysis - Signature assignment classroom management plan - Plagiarism checker usf - English paper - SEARCHING FOR INNOVATION OPPORTUNITIES PROJECT - Problem 7 1a accounting - PPT - Tesla supply chain case study - Density lab report answers - Assignment 300 words - Time value of money - Periodic inventory system journal entries examples - Homeland Security - Life in the Ocean_Week 2