This is a paper that focuses on the SOAP Note analysis of a 56 year old white man. The paper also provides questions to answer for the paper.
The SOAP Note analysis of a 56 year old white man
Week 5 Assignment 2: SOAP Note
A 56-year-old white man presents with an accelerated decline in lung function. Last year you ordered an albuterol inhaler prn and also that seemed sufficient. Today he is dyspneic, pale, and seems almost listless. He continues to smoke, and his pack-year history is 40 years.
CC: “I have to sleep in my recliner because I can’t lie in bed, and I have no energy to do anything—I don’t even have energy to eat.”
Blood pressure: 132/94
Pulse rate: 120 beats/min
Respiration rate: 36/min.
Weight: 160 lbs
AP to lateral diameter: 1:1
Cough with clear mucoid sputum
Diminished breath sounds
Hyperresonance over lung fields on percussion and use of accessory muscles during respiration
Pulmonary function tests: Postbronchodilator FEV1 < 0.6
FEV1/forced vital capacity < 0.7
Chest x-ray film: Small heart, hyperinflation, and flat diaphragm
Arterial blood gases: Arterial hypoxemia and also respiratory acidosis
1. Firstly, what additional subjective data do you think the patient will share?
2. Secondly, what additional objective data will you be assessing for?
3. Thirdly, what National Guidelines are appropriate to consider?
4. Fourthly, what tests will you order?
5. Will you be looking for a consult?
6. What are the medical and also nursing diagnoses?
7. Also, are there any legal/ethical considerations?
8. Additionally, what is your plan of care? Medical, nursing, complementary therapies
9. Subsequently, are there any Healthy People 2020 objectives that you should consider?
10. Using the Circle of Caring, what or who else should be involved to truly hear the patient’s voice, getting him and also the family involved in the care to reach optimal health?
11. What additional patient teaching may be needed?
12. Finally, what billing codes would you recommend?