soap note
DATE AND TIME
S: No events overnight. Pt. complains of… Pt denies HA, changes in vision,
CP, Palpitations, SOB, Nausea, Vomiting, Diarrhea, Constipation, bowel movement and consistency. Tolerated PO meds well. Last bowel movement
Meds:
Antibiotics w: day #
Labs: Also note which labs are pending and any significant changes or trends with arrows.
Cl- BUN
Na
K+ HCO3 Cr
WBC
Hgb
Hct
PT
Glu
Plt
Pulse:
Resp:
BP (w/ range):
I/O::
O: Vitals: Tmax: Tcurr:
Glucose (QAC/HS) |
|
|
|
|
Pulse Ox: x% on x lpm O2, IV access, NGT?, Foley/drains?
Telemetry events, PRN pain meds used
Gen: Pleasant, Friendly, NAD, CAOX3
HEENT: PERRL 3 mm diameter equal round reactive to light, EOMI, anicteric, no scleral injection, no nasal discharge, oropharynx clear w/o ulcers, moist mucous membranes
Neck: no JVD, no adenopathy, no tracheal deviation
CV: RRR, nl S1/S2, no G/R/M, no S3/S4
Pulm: CTA bilaterally, no crackles, wheezes, rhonchi, Good air movement, nl. tactile fremitus
Abd: +BS, Soft, nontender, nondistended, no guarding/ rebounding, no hepatosplenomegaly Ext: DPP/ PTP (doralis pedis/ posterior tibial pulses) 2+ bilateral, no clubbing/ cyanosis/ edema
PTT
INR
Protein
RED 1 Medicine, MS III PN (progress note)
Alb
T. Bili
AST
T.
Dir. Bili
ALT
Alk Phos
ABG (arterial blood gas) pH/ CO2/ O2/ %Sat; time
A: (assessment) 54 y/o white male w/ PMH (past medical history) DM and 20 year pack history with one day h/o pneumonia and day #1 abx (antibiotic) treatment. 1) ID: community acquired pneumonia x1 day with infiltrates in right lower lobe on broad spectrum abx coverage
2) Endo: DM type II, blood sugars are well controlled
3) F/E/N: (fluids/ electrolytes/ nutrition) pt clinically well hydrated, electrolytes wnl
(within normal limits) appropriate nutritional needs met
4) Prophylaxis: pt needs DVT and ulcer prophylaxis
5) Dispo: (disposition) pt willing to try and quit smoking
(usually the organ
S: No events overnight. Pt. complains of… Pt denies HA, changes in vision,
CP, Palpitations, SOB, Nausea, Vomiting, Diarrhea, Constipation, bowel movement and consistency. Tolerated PO meds well. Last bowel movement
Meds:
Antibiotics w: day #
Labs: Also note which labs are pending and any significant changes or trends with arrows.
Cl- BUN
Na
K+ HCO3 Cr
WBC
Hgb
Hct
PT
Glu
Plt
Pulse:
Resp:
BP (w/ range):
I/O::
O: Vitals: Tmax: Tcurr:
Glucose (QAC/HS) |
|
|
|
|
Pulse Ox: x% on x lpm O2, IV access, NGT?, Foley/drains?
Telemetry events, PRN pain meds used
Gen: Pleasant, Friendly, NAD, CAOX3
HEENT: PERRL 3 mm diameter equal round reactive to light, EOMI, anicteric, no scleral injection, no nasal discharge, oropharynx clear w/o ulcers, moist mucous membranes
Neck: no JVD, no adenopathy, no tracheal deviation
CV: RRR, nl S1/S2, no G/R/M, no S3/S4
Pulm: CTA bilaterally, no crackles, wheezes, rhonchi, Good air movement, nl. tactile fremitus
Abd: +BS, Soft, nontender, nondistended, no guarding/ rebounding, no hepatosplenomegaly Ext: DPP/ PTP (doralis pedis/ posterior tibial pulses) 2+ bilateral, no clubbing/ cyanosis/ edema
PTT
INR
Protein
RED 1 Medicine, MS III PN (progress note)
Alb
T. Bili
AST
T.
Dir. Bili
ALT
Alk Phos
ABG (arterial blood gas) pH/ CO2/ O2/ %Sat; time
A: (assessment) 54 y/o white male w/ PMH (past medical history) DM and 20 year pack history with one day h/o pneumonia and day #1 abx (antibiotic) treatment. 1) ID: community acquired pneumonia x1 day with infiltrates in right lower lobe on broad spectrum abx coverage
2) Endo: DM type II, blood sugars are well controlled
3) F/E/N: (fluids/ electrolytes/ nutrition) pt clinically well hydrated, electrolytes wnl
(within normal limits) appropriate nutritional needs met
4) Prophylaxis: pt needs DVT and ulcer prophylaxis
5) Dispo: (disposition) pt willing to try and quit smoking
(usually the organ