Medical Report: Progress Note 1

-

Patient Name: Emily Carter

Date: September 9, 2024
Provider: Dr. Michael Lewis
Visit Type: Follow-up

Chief Complaint:

  • Follow-up for management of asthma and recent exacerbation.

Subjective:

  • Patient reports improvement in asthma symptoms since starting new inhaler. However, occasional wheezing at night persists.

Objective:

  • Vital Signs:
    • Blood Pressure: 118/76 mmHg
    • Heart Rate: 80 bpm
    • Respiratory Rate: 16 bpm
    • Temperature: 98.2°F (36.8°C)
  • Respiratory Exam:
    • Breath sounds clear bilaterally, occasional wheezing noted in the right lower lung field.
  • Medication Adherence:
    • Adheres to new inhaler regimen but reports occasional missed doses.

Assessment:

  • Asthma symptoms partially controlled with current medication. Persistent nocturnal wheezing may indicate suboptimal control.

Plan:

  • Continue current inhaler therapy.
  • Increase the frequency of the use of the inhaled corticosteroid.
  • Educate patient on proper inhaler technique and the importance of regular use.
  • Schedule follow-up appointment in 4 weeks to assess control and review asthma action plan.

Komentar

Posting Komentar

Postingan populer dari blog ini

EAP: Reading text for nursing students

-
Text 1 For nursing students, 1. .. in daily activities is crucial for both academic success and personal well-being. 2 ... tasks such as studying, attending classes, and participating in clinical practice not only enhance their knowledge and skills but also 3 ... to their overall health. For example, 4 ... personal hygiene and preparing healthy meals can boost energy levels and 5. .. concentration, which is essential for rigorous nursing coursework. Incorporating regular physical activity, such as exercise or even walking between classes, 6. .. reduce stress and 7 ... mental clarity. Additionally, 8 ... time management skills through structured daily activities can 9 ... a sense of accomplishment and 10 ... students balance their studies with personal life. Text 2 Welcome to this guide on how to be successful in studying English as a nursing student. Mastering English is essential for your studies and future career, so let’s explore some effective strategies. 1. Understand the Vocab...
Baca selengkapnya

Simple Past Tense

-
Its form describes actions that were completed in the past. For example, “I visited my grandmother last weekend.” The simple past is typically formed by adding "-ed" to regular verbs, while irregular verbs have unique forms (e.g., “go” becomes “went”). Affirmative Form: Subject + past verb (regular/irregular) + (object) Negative Form: Subject + did not (didn’t) + base verb + (object) Question Form: Did + subject + base verb + (object)? Adverbs: yesterday, last week, last month, last year, a week ago, earlier, in 2010  be careful > quickly, carefully, suddenly, happily be careful > always, often Examples Affirmative: Regular Verb: She walked to the store. They played soccer yesterday. Irregular Verb: He went to the party last week. I saw a great movie on Friday. Negative: Regular Verb: She did not walk to the store. They did not play soccer yesterday. Irregular Verb: He did not go to the party last week. I did not see a great movie on Friday. Question: Regular Ve...
Baca selengkapnya

KALIMAT DAN KALIMAT EFEKTIF DALAM PENULISAN (2)

-
 Contoh paragraf tidak efektif 1. Di zaman modern ini, banyak orang menggunakan teknologi untuk berbagai keperluan. Teknologi sudah menjadi bagian penting dalam kehidupan sehari-hari, dan orang-orang sangat bergantung padanya. Oleh karena itu, penting bagi kita untuk memahami bagaimana teknologi berfungsi dan bagaimana kita bisa memanfaatkannya dengan baik. Dengan teknologi, kita bisa melakukan banyak hal. Kita bisa berkomunikasi, bekerja, dan belajar dengan lebih mudah. Namun, ada juga tantangan yang dihadapi, seperti masalah privasi dan keamanan. Maka dari itu, kita perlu memikirkan semua aspek ini. 2. Cuaca hari ini sangat beragam. Di pagi hari, langit cerah dan matahari bersinar. Namun, siang hari tiba-tiba hujan deras. Banyak orang yang keluar rumah, dan mereka semua menggunakan payung. Beberapa orang tampak bahagia, tetapi yang lain tidak. Setelah hujan reda, langit kembali cerah. Cuaca memang sulit diprediksi, dan ini membuat kita harus selalu siap. 3. Belajar...
Baca selengkapnya