Get Solved NR 509 Week 2 SOAP Note Template (Multiple Versions)

Get Solved NR 509 Week 2 SOAP Note Template Multiple Versions

NR 509 Week 2 SOAP Note Template (Version 1)

History of Present Illness (HPI)

• Chief Complaint (CC): “Breathing problems”
• Onset: Diagnosed with asthma at age 2 and ½ years; exacerbation two days ago
• Location: Chest and Lungs
• Duration: Two days ago. Episodes occur approximately every 4 hours or “5 times a day”
• Characteristics: SOB not well relieved by inhaler, DOE, wheezing, difficulty breathing while lying flat, dry cough, waking at night due to SOB
• Aggravating Factors: Exposure to cats and dust. Bursts of physical exertion “run upstairs to class.” “Past couple of days, though it doesn’t seem like anything, in particular, is causing it.”
• Relieving Factors: Proventil inhaler. “Once I use my inhaler it only takes a minute or two for my breathing to go back to normal…that’s not what’s been happening recently, though.”
• Treatment: Proventil inhaler
  

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NR 509 Week 2 SOAP Note Template (Version 2)

History of Present Illness (HPI)

• Chief Complaint (CC): Recent asthma attack which is not fully resolved
• Onset: 2 days ago, while visiting a cousin with cats
• Location: N/A
• Duration: 2 days
• Characteristics: Chest tightness, worse when laying down & at night. Persistent cough x2 days
• Aggravating Factors: Physical activity, laying down
• Relieving Factors: Proventil inhaler, less effective than usual
• Treatment: Proventil inhaler
  

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NR 509 Week 2 SOAP Note Template (Version 3)

• Chief Complaint (CC): “My throat has been sore…and itchy. And my nose won’t stop running. These symptoms are driving me nuts.”
• Onset: “2-7 days” Location: Throat, 4/10
• Duration: Steady weight loss, 3-5 pounds per week
• Characteristics: “sore” throat…”just clear” discharge from nose…no congestion, no cough…no fever…no change in diet…able to stay hydrated
• Aggravating Factors: “not that I know of”
• Relieving Factors: Small, bland meals are better-tolerated Treatment: None reported, lozenge
  

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NR 509 Week 2 SOAP Note Template (Version 4)

• Chief Complaint (CC): Sore itchy throat and runny nose
• Onset: 1 week ago Location: throat and nose
• Duration: constant runny nose, sore, itchy throat
• Characteristics: constant runny nose with clear discharge. Describes throat pain as 4/10 and sore.
• Aggravating Factors: denies aggravating factors for runny nose. Hurts more upon swallowing.
• Relieving Factors: sucking candies and drinking water improves throat symptoms. Denies relieving factors for runny nose.
• Treatment: Denies OTC medications

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