SOAPAssistV00 / Docs /Tylor.txt
AbeerTrial's picture
Duplicate from AbeerTrial/SOAPAssist
35b22df
raw
history blame contribute delete
542 Bytes
Subjective: Jerry reported sudden onset of severe chest pain.
Objective: Vital signs: Blood pressure: 140/90 mmHg, Pulse: 80 bpm, Respiratory rate: 16 breaths/min, Oxygen saturation: 98% on room air.
Assessment: Jerry is likely experiencing a cardiac event and is in need of further assessment and treatment.
Plan: 1. Administer oxygen via nasal cannula at 2L/min.
2. Obtain an electrocardiogram (ECG) and order laboratory tests.
3. Administer aspirin 325 mg orally.
4. Refer Jerry to a cardiologist for further assessment and treatment.