Respiratory Care Practicum
Krystle Henley
Respiratory Care Practicum I
18 August 2011 Soap Notes for Soap 1
Subjective - Upon physical examination, patient presents as a morbidly obese senior woman who appears older than her age. Patient presents with sudden onset vomiting and nausea. Patient is has recently undergone surgery on her lower back and is complaining of pain in and around the incision area. Patient has a home O2 requirement of 4 L/min at resting and 5 L/min during physical activity. Patient’s current respiratory rate is 24 on 6 L/min nasal canula. Patient’s voice was faint and slightly horse.
Objective –Patient is now presenting with a normal breathing pattern with a HR of 110 bpm, BP of 117/80 and a RR of 16 on 8L/min via Oxymizer. Trachea slightly
Respiratory Care Practicum I
18 August 2011 Soap Notes for Soap 1
Subjective - Upon physical examination, patient presents as a morbidly obese senior woman who appears older than her age. Patient presents with sudden onset vomiting and nausea. Patient is has recently undergone surgery on her lower back and is complaining of pain in and around the incision area. Patient has a home O2 requirement of 4 L/min at resting and 5 L/min during physical activity. Patient’s current respiratory rate is 24 on 6 L/min nasal canula. Patient’s voice was faint and slightly horse.
Objective –Patient is now presenting with a normal breathing pattern with a HR of 110 bpm, BP of 117/80 and a RR of 16 on 8L/min via Oxymizer. Trachea slightly