Soap Note

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Krystle Henley
Respiratory Care Practicum I
18 August 2011
Soap Notes for Soap 1

Subjective - Upon physical examination, patient presents as a morbidly obese senior woman who appears older than her age. Patient presents with sudden onset vomiting and nausea. Patient is has recently undergone surgery on her lower back and is complaining of pain in and around the incision area. Patient has a home O2 requirement of 4 L/min at resting and 5 L/min during physical activity. Patient’s current respiratory rate is 24 on 6 L/min nasal canula. Patient’s voice was faint and slightly horse.

Objective –Patient is now presenting with a normal breathing pattern with a HR of 110 bpm, BP of 117/80 and a RR of 16 on 8L/min via Oxymizer. Trachea slightly deviated to the left side. Left and right lower lung field had dull percussion note with coarse crackles upon auscultation as well as diminished breath sounds throughout on right and left apecies. Scattered wheezes observed throughout. A CXR revealed opacifications seen in both lung bases which appear to be increased on the right side indicating the presents of atalectasis. Lab results are as follows: RBC – 2.74, Hb – 7.9, HcT 24.4, WBC – 9.30, Na+ - 131, K+ - 4.7 and Cl- - 94. ABG results are as follows: pH -7.41, HCO3 – 33, PaCO2 – 53, PaO2 – 75. ABG interpriation –

Assessment - Left and right lower lung fields present coarse crackles upon auscultation. Clear and diminished on the top of the longs. Slight expiratory wheezes scattered throughout. CXR is showing the presents of atalectasis or pneumonia.

Plan - Physician ordered patient to begin treatments with Duo nebulizer Q4, Pulmucort BID and Xopenex Q2/PRN to help the patient maintain proper lung function.
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