FIVE Acute care soap notes related to a patient been seen by a doctor in a hospital setting in the meds urge floor or Intensive care unit. Soap note must contain: 1-HPI, 2-PMH, 3-ALLERGY, 4-CURRENTS MEDS, 5-OBJECTIVE DATE AS VITAL SIGNS, 6-ASSESSMENT ( ACTUAL DX), 7-PLAN,8-  3 DIFFERENTIAL DX AND 9- TREATMENT. DONT NEED TO BE LONG JUST NEED TO MENTION THEM PATIENT BEEN SEEN IN A HOSPITAL SETTING DUE TO A PARTICULAR CHIEF COMPLAINT. FOR MARCH 8, 2022

SOAP Note 1: March 8, 2022

Subjective:
The patient, a 65-year-old male with a history of hypertension and diabetes, is admitted with a chief complaint of shortness of breath. The patient reports that the symptoms started suddenly two days ago and have progressively worsened. He denies any chest pain or cough but notes a slight fever. The patient also mentions feeling fatigued and experiencing a productive cough with yellow sputum. No recent travel or sick contacts.

Objective:
Vital Signs:
– Blood Pressure: 150/90 mmHg
– Heart Rate: 100 bpm
– Respiratory Rate: 24 breaths per minute
– Temperature: 38.2°C
– Oxygen Saturation: 90% on room air

Assessment:
1. Differential Diagnosis:
– Pneumonia
– Acute bronchitis
– Exacerbation of chronic obstructive pulmonary disease (COPD)

2. Actual Diagnosis: Pneumonia

Plan:
– Administer oxygen supplementation via nasal cannula to maintain oxygen saturation above 94%
– Initiate empiric antibiotic therapy with azithromycin
– Obtain sputum culture and sensitivity
– Order a chest X-ray
– Encourage deep breathing and coughing exercises
– Provide patient education on the importance of completing the full course of antibiotics
– Schedule a follow-up appointment in one week for reevaluation

SOAP Note 2: March 8, 2022

Subjective:
The patient, a 45-year-old female with a history of asthma, presents with a chief complaint of wheezing and chest tightness. She reports that these symptoms have been present for the past three days and have been worsening despite her regular use of rescue inhalers. The patient mentions exposure to a cat earlier in the week, and she has a known allergy to cats.

Objective:
Vital Signs:
– Blood Pressure: 130/80 mmHg
– Heart Rate: 80 bpm
– Respiratory Rate: 18 breaths per minute
– Temperature: 37.0°C
– Oxygen Saturation: 95% on room air

Assessment:
1. Differential Diagnosis:
– Asthma exacerbation
– Allergic reaction

2. Actual Diagnosis: Asthma exacerbation

Plan:
– Administer a nebulized bronchodilator (albuterol) and corticosteroid (methylprednisolone)
– Assess lung function with spirometry before and after bronchodilator administration
– Order allergy testing to confirm the presence of cat allergies
– Provide patient education on asthma triggers and avoidance strategies
– Schedule a follow-up appointment in two weeks for asthma management review

SOAP Note 3: March 8, 2022

Subjective:
The patient, a 55-year-old male with a history of diabetes and peripheral vascular disease, presents with a chief complaint of non-healing foot ulcer. The patient reports that the ulcer has been present for three weeks and is associated with foul-smelling discharge. He denies any fever or constitutional symptoms.

Objective:
Vital Signs:
– Blood Pressure: 140/80 mmHg
– Heart Rate: 70 bpm
– Respiratory Rate: 16 breaths per minute
– Temperature: 37.5°C
– Oxygen Saturation: 98% on room air

Assessment:
1. Differential Diagnosis:
– Diabetic foot ulcer with infection
– Peripheral arterial disease
– Cellulitis

2. Actual Diagnosis: Diabetic foot ulcer with infection

Plan:
– Assess wound for signs of infection, including redness, warmth, and purulent discharge
– Order wound culture and sensitivity
– Initiate broad-spectrum antibiotic therapy (amoxicillin-clavulanate)
– Provide wound care and debridement as necessary
– Consult vascular surgery for further evaluation and potential intervention
– Schedule a follow-up appointment in one week for wound reassessment

SOAP Note 4: March 8, 2022

Subjective:
The patient, a 72-year-old female with a history of hypertension and atrial fibrillation, is admitted with a chief complaint of palpitations and dizziness. The patient describes the symptoms as sudden onset and intermittent. She reports feeling lightheaded and weak during the episodes.

Objective:
Vital Signs:
– Blood Pressure: 160/90 mmHg
– Heart Rate: 120 bpm
– Respiratory Rate: 16 breaths per minute
– Temperature: 37.0°C
– Oxygen Saturation: 97% on room air

Assessment:
1. Differential Diagnosis:
– Atrial fibrillation with rapid ventricular response
– Supraventricular tachycardia
– Cardiac arrhythmia

2. Actual Diagnosis: Atrial fibrillation with rapid ventricular response

Plan:
– Obtain a 12-lead electrocardiogram (ECG) to confirm the diagnosis
– Initiate rate control with intravenous diltiazem
– Assess electrolyte levels, including potassium and magnesium
– Consult cardiology for further evaluation and management
– Schedule a follow-up appointment in one week for arrhythmia management discussion