As for this patient, or for any patient for that matter, it is vital that the past medical history of the patient should be asked as to the diagnosis, date of onset, duration and medical management. The chief complaint was present, however, it still lacked in some aspects such as the onset of the complaint, duration and precipitating and relieving factors (though in this scenario, one relieving factor was given for the SOB). Lloyd & Craig (2007) noted that the medication history of the patient is "crucially important" and should not only consider the current medications but include as well past medications. For this patient, history of smoking or for any smokers in the household should be asked because of his cardiovascular risk.
For physical examinations, important body systems which should be checked should include the cardiovascular system, respiratory system and the muscular system, particularly the lower extremity muscle and joints. The cardiovascular system should be checked because of the presence of the lower extremity swelling (dependent edema), sudden weight gain and breathlessness. The respiratory system should also be checked because of the complaint of SOB. The specific examination findings from the scenario should be documented on the objective part of the SOAP notes. ...Show more