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Problem based SOAP notes for three patients - Essay Example

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This is a 72 year old black male, retired school teacher who is presenting with symptoms of erectile dysfunction. He describes that he is able to have an erection but it does not stay long enough to participate in intercourse. He was diagnosed three years ago with Type 2 diabetes and is somewhat hypertensive…
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Problem based SOAP notes for three patients
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Download file to see previous pages B. Renal Panel in three months
C. Instruct on diabetic diet.
D. Instruction in side effects of Viagra.
E. Diabetes education
F. Seatbelt at all times in Motor Vehicle
G. Influenza Vaccine (Seasonal/H1N1)--hand washing
H. Foot care checks and maintenance education
I. Skin checks of all moles and other changes.
Narrative Report to Preceptor (After initial assessment).
This is a 72 year old black male, retired school teacher who is presenting with symptoms of erectile dysfunction. He describes that he is able to have an erection but it does not stay long enough to participate in intercourse. He was diagnosed three years ago with Type 2 diabetes and is somewhat hypertensive. His medications consist of Metformin for the diabetes and Lopressor for the hypertension.
Physical exam results in normal vital signs as well as normal heart and lung sounds. There is no tenderness in the abdomen. Range of motion shows some tenderness in his shoulders. His labs are normal but he does have slight sugar in his urine.
I suggest that we do a trail of Viagra as this drug does not affect his other drugs. There is also a need to increase his Metformin to maximum dose and leave his Lopressor at the same dose for present. We will start conservative treatment on the shoulder tenderness with NSAIDS and pool therapy. He has not been having regular checkups with hemoglobin A1C results and I suggest that take place every three months along with a renal panel. instruction in diabetic diet and blood sugar testing at home as well as instruction in understanding how to check his feet and what the does and don't there are.
Subjective Data (S)
CC/chief complaint: "I have pain in my right big toe. It...
His labs are normal but he does have slight sugar in his urine.
I suggest that we do a trail of Viagra as this drug does not affect his other drugs. There is also a need to increase his Metformin to maximum dose and leave his Lopressor at the same dose for present. We will start conservative treatment on the shoulder tenderness with NSAIDS and pool therapy. He has not been having regular checkups with hemoglobin A1C results and I suggest that take place every three months along with a renal panel. instruction in diabetic diet and blood sugar testing at home as well as instruction in understanding how to check his feet and what the does and don't there are.
This is a 38 YO WM, obese complaining of severe pain in right great toe. Toe is swollen and painful to touch. States it woke him up in the middle of the night and is getting worse. Uric acid level is high. Blood pressure is borderline. Physical exam is unremarkable with the exception of the right toe and the obesity.
I suggest we order Ibuprofen at top dose for inflammation reduction and pan control. Cochicine will need to be ordered at a loading dose of 1.2 mg PO and 0.5 mg every hour until pain and swelling decreases or up to 8 mg for this attack. We should then put him on a maintenance dose of 0.5 mg PO daily three times a week on Mon. Wed. and Fri. ...Download file to see next pagesRead More
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