NURS 6512N Week 5 Discussion Post. Advanced Health Assessment
Discussion Post Week 5 – Assessing the Ears, Nose, and Throat
Cynthia Nwokocha
NURS 6512N-24 – Advanced Health Assessment
Discussion Post Week 5 – Assessing the Ears, Nose, and Throat
Cynthia Nwokocha
June 26, 2017
Comprehensive SOAP Note
Purpose: To demonstrate what each section of the SOAP Note should include. Remember
that nurse practitioners treat patients in a holistic manner, and your SOAP Note should
reflect that premise.
Patient Initials: NN Age: 62 Gender: Male
SUBJECTIVE DATA:
Chief Complaint (CC): Coughing up phlegm and fever
History of Present Illness (HPI): Sara Jones is a 65-year-old Caucasian female who
presents today with a productive cough x 3 weeks and fever for the last 3 days. She
reported that the “cold feels like it is descending into her chest.” The cough is nagging
and productive. She brought in a few paper towels with expectorated phlegm –
yellow/brown in color. She has associated symptoms of dyspnea of exertion and fever.
Her Tmax was reported to be 102.4 last night. She has been taking Ibuprofen 400mg
about every 6 hours and the fever breaks, but it returns after the medication wears off.
She rated the severity of her symptom discomfort at 4/10.
Medications:
1.) Lisinopril 10mg daily
2.) Combivent 2 puffs every 6 hours as needed
3.) Serovent daily
4.) Salmeterol daily
5.) Over-the-counter Ibuprofen 200mg -2 PO as needed
6.) Over-the-counter Benefiber
7.) Flonase 1 spray each night as needed for allergic rhinitis symptoms
Allergies:
Sulfa drugs - rash
Past Medical History (PMH):
1.) Emphysema with recent exacerbation 1 month ago – deferred admission – RX’d with
outpatient antibiotics and hand held nebulizer treatments.
2.) Hypertension – well controlled
3.) Gastroesophageal reflux (GERD) – quiet, on no medication
This study so
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https://www.coursehero.com/file/24706630/Week-5-Discussion-Postdocx/
, NURS 6512N Week 5 Discussion Post. Advanced Health Assessment
Discussion Post Week 5 – Assessing the Ears, Nose, and Throat
Cynthia Nwokocha
4.) Osteopenia
5.) Allergic rhinitis
This study so
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https://www.coursehero.com/file/24706630/Week-5-Discussion-Postdocx/
Discussion Post Week 5 – Assessing the Ears, Nose, and Throat
Cynthia Nwokocha
NURS 6512N-24 – Advanced Health Assessment
Discussion Post Week 5 – Assessing the Ears, Nose, and Throat
Cynthia Nwokocha
June 26, 2017
Comprehensive SOAP Note
Purpose: To demonstrate what each section of the SOAP Note should include. Remember
that nurse practitioners treat patients in a holistic manner, and your SOAP Note should
reflect that premise.
Patient Initials: NN Age: 62 Gender: Male
SUBJECTIVE DATA:
Chief Complaint (CC): Coughing up phlegm and fever
History of Present Illness (HPI): Sara Jones is a 65-year-old Caucasian female who
presents today with a productive cough x 3 weeks and fever for the last 3 days. She
reported that the “cold feels like it is descending into her chest.” The cough is nagging
and productive. She brought in a few paper towels with expectorated phlegm –
yellow/brown in color. She has associated symptoms of dyspnea of exertion and fever.
Her Tmax was reported to be 102.4 last night. She has been taking Ibuprofen 400mg
about every 6 hours and the fever breaks, but it returns after the medication wears off.
She rated the severity of her symptom discomfort at 4/10.
Medications:
1.) Lisinopril 10mg daily
2.) Combivent 2 puffs every 6 hours as needed
3.) Serovent daily
4.) Salmeterol daily
5.) Over-the-counter Ibuprofen 200mg -2 PO as needed
6.) Over-the-counter Benefiber
7.) Flonase 1 spray each night as needed for allergic rhinitis symptoms
Allergies:
Sulfa drugs - rash
Past Medical History (PMH):
1.) Emphysema with recent exacerbation 1 month ago – deferred admission – RX’d with
outpatient antibiotics and hand held nebulizer treatments.
2.) Hypertension – well controlled
3.) Gastroesophageal reflux (GERD) – quiet, on no medication
This study so
©urc2e0w1a4s dLowanulroeadaetdebyE1d0u00c0a0t8io32n5,58In06c4. from Page 1 of
https://www.coursehero.com/file/24706630/Week-5-Discussion-Postdocx/
, NURS 6512N Week 5 Discussion Post. Advanced Health Assessment
Discussion Post Week 5 – Assessing the Ears, Nose, and Throat
Cynthia Nwokocha
4.) Osteopenia
5.) Allergic rhinitis
This study so
©urc2e0w1a4s dLowanulroeadaetdebyE1d0u00c0a0t8io32n5,58In06c4. from Page 2 of
https://www.coursehero.com/file/24706630/Week-5-Discussion-Postdocx/
