NR 601 Week 1 Part 2 discussion
Vital signs: BP 138/88; HR 88 (regular), RR 18, T 98.8 height 5'7", weight 175 pounds
General appearance: Thin and mildly dyspneic
Lungs: Mild end-expiratory wheezing. Pursed-lip breathing noted and has a prolonged expiratory phase. Heart: S1 and S2 RRR with distant heart tones. No murmurs
Abdomen: Soft, non-tender with positive bowel sounds. No abdominal bruits
Extremities: Full ROM of all extremities. No edema. All pulses 2+
Labs/diagnostics: Chest x-ray shows pulmonary hyperinflation, flattening of the diaphragm; Pulmonary function test:
Prebronchodilation: FEV1/FVC ratio 53%, FEV1 50% of predicted value
Postbronchodilation with 2 puffs albuterol—FEV1/FVC ratio 0.60, FEV1 60% of predicted value
Discussion Questions Part Two:
Post your SOAP note for this patient's encounter.
Review the SOAP note format for the course. Summarize the history and results of the physical exam. Include one evidence-based journal article that supports your rationale for all diagnoses with ICD 10 codes and include a complete treatment plan that include medications, further diagnostics, patient education, referral and plan for follow-up. Each step of the plan must include an in-text citation to a scholarly source. Review the Reference Guidelines document in Course Resources.