NURS 623 SOAP note adult 2 pneumonia and PE.

NURS 623 SOAP note adult 2 pneumonia and PE. Chief Complaint Shortness of breath and still not feeling well History of Present Illness A 72-year-old male presents to with shortness of breath while at rest and that it gets worse with movement. Pt complains of “not feeling well” even after taking all of his azithromycin last week. Patient reports a productive cough. Patient complains of pain in lungs with coughing. Pain is at a 4/10. Patient was on azithromycin and finished dosing yesterday and thought he hasn’t really felt any better since starting the antibiotic. Past Medical History Past Medical history: hypertension Past surgical history: Left Hip replacement in 2012 Patient is current in his immunizations No Medication or seasonal allergies Current medications include Lisinopril 10mg PO QD. Family History Include parents, siblings; grandparents if applicable/known, cause of death, age, pertinent medical illnesses Mother: Asthma, hypertension and type 2 diabetes Died at 92 of natural causes Father: Hypertension died at 82 of CVA Brother: Asthma, type 2 Diabetes Personal/Social History Education, marital status, occupation, alcohol/drug use, smoking status, sexual history if relevant, exercise, nutrition, religious preference if known Patient has a Bachelors degree in Accounting and is retired. Patient is widowed and has son and daughter that help take care of him. Pt denies any alcohol or illicit drug use. He does not smoke or use chewing tobacco. Pt does not moderate exercise and is on a regular diet. Review of Systems (as applicable to CC) • General: Positive for fever and fatigue. Negative for chills, lethargy, and night sweats • Hair, Skin, & Nails: Negative for rashes or lesions. Negative for nail changes. Negative for hair loss.