Ethical SOAP Note

Danial Ramadhan

03/4/2021 19:45
Mr. B 66 year old, male
Referral: none
Source and Reliability : Self , both reliable sources.

S (Subjective):

Chief complaint : “ shortness of breath and fatigue.”

HPI: before being admitted to the hospital the patient said he had shortness of
breath after doing the activity, heart palpitations, tired easily, The patient said he
was experiencing shortness of breath , does not decrease even when rest, dizziness
and weakness

Past medical history : The patient said that he had a history of heart disease, and
several years after being treated, the patient was never controlled again after being
treated
Family history : The patient says that no family member has experienced illness
like him.

Allergies: NKA
Current Mediation: Metformin 500 mg

Social History: patients live with their children and grandchildrenthe patient does
not smoke and does not drink alcohol
Exercise & Diet: No diet

O (Objective)/Physical Exam

VS – BP: 153/80 mg/dl , HR: 80, RR: 28, Temp 37 C, weight: 53 kg , height: 149
cm.

Mr. B feeling tight, dizzy, the body is easily tired, there is chest wall retraction
The chest looks symmetrical, there are respiratory muscles , Sonor lung sound
Breath sounds: wet ronchi / crales, there is nasal cupping, pale lip mucosa, the
patient looks restless

A (Assessment)

Problem #1 – ineffective breathing patterns associated with shortness of breath

Plan (P): After the effective breathing pattern is carried out with the criteria for
normal breathing results, no shortness of breath, no breath in the nostrils, normal
lip mucosa, normal breath sounds, normal lung sounds

Therapy/Treatment: Monitor the number of breaths, Monitor vital signs, Instruct

patient to fowler position so that neck does not bend, Teach breathing techniques
and proper relaxation
Evaluation : Subjective evaluation, namely clients who feel shortness of breath is
reduced with activity and do not have difficulty breathing. The objective
evaluation of the client appears that it is not difficult to breathe, blood pressure:
120/80 mmHg, pulse 80x / minute .