NSG 6001: SOAP NOTE WEEK 2 WELL
EXPLAINED RATED A+ DOWNLOAD TO SCORE A
WITH REFERENCES
Week 2 Soap
Note South
University NSG
6001
Kaley Mills
February 28, 2020
, NSG 6001: SOAP NOTE WEEK 2 WELL
EXPLAINED RATED A+ DOWNLOAD TO SCORE A
WITH REFERENCES
Subjective: 65-year-old Caucasian female
Chief Complaint: The patient presents today complaining of “severe wheezing, shortness of
breath and coughing at least once daily”.
HPI: Patient is a 65-year-old Caucasian female who was hospitalized ten weeks prior to today,
from a motor vehicle accident which induced post traumatic seizures beginning two weeks after
the crash. She was started on Phenytoin SR capsules 300mg PO QHS which ceased all seizure
activity since initiation. In addition to her wheezing, coughing, and shortness of breath reported
today, she also states she has been having more than four asthma attacks per week over the last
two months and dyspnea with exertion. She is displaying dyspnea at rest and reports taking
Albuterol once today.
Medications:
• Theophylline SR Capsules 300 mg PO BID effective bronchodilator given for
Asthma (Dunphy, 2019).
• Albuterol inhaler, PRN for shortness of breath and dyspnea related to asthma.
• Phenytoin SR capsules 300 mg PO QHS for post traumatic seizures.
• HTCZ 50 mg PO BID diuretic for congestive heart failure.
• Enalapril 5 mg PO BID ace inhibitor for hypertension from congestive heart failure.
EXPLAINED RATED A+ DOWNLOAD TO SCORE A
WITH REFERENCES
Week 2 Soap
Note South
University NSG
6001
Kaley Mills
February 28, 2020
, NSG 6001: SOAP NOTE WEEK 2 WELL
EXPLAINED RATED A+ DOWNLOAD TO SCORE A
WITH REFERENCES
Subjective: 65-year-old Caucasian female
Chief Complaint: The patient presents today complaining of “severe wheezing, shortness of
breath and coughing at least once daily”.
HPI: Patient is a 65-year-old Caucasian female who was hospitalized ten weeks prior to today,
from a motor vehicle accident which induced post traumatic seizures beginning two weeks after
the crash. She was started on Phenytoin SR capsules 300mg PO QHS which ceased all seizure
activity since initiation. In addition to her wheezing, coughing, and shortness of breath reported
today, she also states she has been having more than four asthma attacks per week over the last
two months and dyspnea with exertion. She is displaying dyspnea at rest and reports taking
Albuterol once today.
Medications:
• Theophylline SR Capsules 300 mg PO BID effective bronchodilator given for
Asthma (Dunphy, 2019).
• Albuterol inhaler, PRN for shortness of breath and dyspnea related to asthma.
• Phenytoin SR capsules 300 mg PO QHS for post traumatic seizures.
• HTCZ 50 mg PO BID diuretic for congestive heart failure.
• Enalapril 5 mg PO BID ace inhibitor for hypertension from congestive heart failure.
