SOAP NOTE

WaldenUniversityAssessing the Heart, Lungs and Peripheral VascularSystemCourse Instructor

Subjetive:&nbsp

A 40 year old man visited the clinicand gave his personal history he stated that he had been at risk ofpollution since the place he lives has a lot of industrial pollutant.When exercising at the morning and in the afternoon he had problemsin breathing and posed difficulties when doing exercise (Seidel etal., 2011). The environment he lives is exposed to cold, dust andallergens. He is a chain smoker and he takes more than two packets ofcigarette everyday but he does not drink alcohol and other substanceabuse.

The vital sign that were observedwas that the skin was colored and pink. The patient weight was 128lbs and a height of 5.9 and 18 respiration per minute. The breath wasnot consecutive and it was observed it was rapid and shallow, andprolonged exhales (Ball et al., 2015). The legs were swollen but didnot have any difficulty in walking.

Chest examination was carried andthe stethoscope indicated that the patient had wheezing sound, noisein the chest and the breath rate kept on changing. The veins had alot of pressure which made the patient not to sleep well (Dains,Baumann and Scheibel, 2012). The patient had prolonged cough.

Assessments

Dizziness

Fatigue

Prolonged cough

The patient complained the coughingis at night made him to have sleepless night. The second is symptomsthat are worse at night and at day time they disappear. Sneezing whenexposed to cold air or allergens and recurrent wheezing.

Planning

Deep breathing was encouraged andeating of well balanced diet to avoid excessive weight loss(Sullivan, 2012). Inhaled corticosteroids was prescribed for thepatient and advised to stay in areas that will not trigger asthma.

References:

Ball, J. W., Dains, J. E., Flynn, J.A., Solomon, B. S., &amp Stewart, R. W. (2015). Seidel`s guide tophysical examination (8th ed.). St. Louis, MO: Elsevier Mosby.

Dains, J. E., Baumann, L. C., &ampScheibel, P. (2012). Advanced health assessment and clinicaldiagnosis in primary care (4th ed.). St. Louis, MO: Elsevier Mosby.

Seidel, H. M., Ball, J. W., Dains,J. E., Flynn, J. A., Solomon, B. S., &amp Stewart, R. W. (2011).Physical exam summary: Blood vessels. In Mosby`s guide to physicalexamination (7th ed.). St. Louis, MO: Elsevier Mosby.

Sullivan , D. D. (2012). Guide toclinical documentation (2nd ed.). Philadelphia, PA: F. A. Davis.