Making a soap note for this scenario

Reference no: EM133297274

Question: MAKING A SOAP NOTE FOR THIS SCENARIO

Your patient Mrs. Peacock, age 63, presents with a fever, chills, productive cough with thick yellow secretions. Mrs. Peacock smoked a pack and a half a day from the time she was 18 until two years ago when she quit. Presenting at the ER on room air, her HR is 114, temp 102 F, respiratory rate 27 and labored/shallow. Her SpO2 via finger probe is reading 85% with a good waveform/pleth. ABG reveals: pH 7.31, PaCO2 59, PaO2 55, HCO3 32, BE + 10. She is using her accessory muscles for breathing and pursing her lips on exhalation. She is leaning over on the table with her elbows propping her torso up.

She has an increased tactile fremitus. Breath sounds are diminished bilaterally at the bases with soft expiratory wheezes bilaterally throughout. She also has faint course crackles on the right side. Her percussion note is flat on the right lower lobe and hyper resonant in all other lung fields.

She seems to have a barrel chest and is cyanotic looking with JVD, and edema in her hands and feet. This is the second year in a row that she has had to come to the ER with these same symptoms.

Reference no: EM133297274

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