Evans. Week1. Soap nr601 - Patient Information L J 65 y\/o Male Hispanic S CC Shortness of breath HPI include all the information regarding the CC using

Evans. Week1. Soap nr601 - Patient Information L J 65 y/o...

This preview shows page 1 - 3 out of 5 pages.

Patient Information: L. J., 65 y/o, Male, Hispanic S. CC: “ Shortness of breath.” HPI : include all the information regarding the CC using the OLDCARTS format. If the CC was “Unintentional weight loss”, the OLDCARTS for the HPI might look like the following example: Onset:3 months ago Location: Respiratory system (lungs) Duration: Unknown Characteristics: Worsening shortness of breath Aggravating Factors: Daily Activities Relieving Factors: n/a Treatment: None reported Severity: Pursed lip breathing Current Medications : Ibuprofen 600 mg po tid, (used for pain, unknown length of time) Lisinopril 20 mg po QD (used for htn, unknown length of time) Hydrochlorothiazide 25 mg po QD (used for htn, unknown length of time) Simvastatin 20 mg po QD (used for high cholesterol, unknow length of time) Meloxicam 7.5 mg QD (used for osteoarthritis, unknown length of time) Allergies: NKA PMHx : Hypertension, cataracts, and osteoarthritis, left knee arthroplasty in 2013 Soc Hx: 65 pack year history of cigarette smoking; denies alcohol intake or illicit drug use; is married and recently retired. Fam Hx : Father has history of HTN; Mother has history of “mild” stroke; Brother has a history of hyperlipidemia. ROS : CONSTITUTIONAL: Denies weight loss, fever. CARDIOVASCULAR: Denies chest pain, chest pressure or chest discomfort. Denies palpitations or edema. RESPIRATORY: Reports shortness of breath, cough and sputum.
Image of page 1
ALLERGIES: Denies history of asthma, hives, eczema or rhinitis. O. Physical exam Vital signs : BP 138/88; HR 88 (regular), RR 18, T 98.8 height 5’7”, weight 175 pounds CONSTITUTIONAL: No weight loss, fever. General appearance : Thin and mildly dyspneic Cardiovascular : S1 and S2 RRR with distant heart tones. No murmurs. No edema. All pulses 2+.
Image of page 2
Image of page 3

You've reached the end of your free preview.

Want to read all 5 pages?

  • Fall '16
  • Chronic obstructive pulmonary disease, Schub

  • Left Quote Icon

    Student Picture

  • Left Quote Icon

    Student Picture

  • Left Quote Icon

    Student Picture