I need help making a SOAP note
I need help making a SOAP note for this scenario Your patient, Brody Cody, is an 18 year old boy who was just involved in a 4-wheeler accident at Wayahutta. He presents with pain on the right side and difficulty breathing. Thankfully, he was wearing a helmet but did roll over 3 times. Upon examination, he has pain to the touch on the right throax, trachea is deviated to the left. He has a hyperresonant percussion note on the right side, resonant on the left. Diaphragmatic excursion is decreased on the right side. The patient is breathing shallow at a rate of 31, HR 123, SpO2 84% on a non-rebreather mask at 10lpm. With every breath, the bag collapses completely on inhalation. No known allergies, no medications presently. Breath sounds reveal absent on the right, diminished throughout on the left. ABG reveals: pH 7.49, PaCO2 30, PaO2 52, HCO3 23, BE 1. SCIENCE HEALTH SCIENCE NURSING NUR 112
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