Soap Notes 2 Professor: Dr. DATE, 2012 Patient name: S.M. Evaluated as patient admit, hospitalist Follow up. Subjective: Cc: recurring headache and sore throat. S.M. is a 60 year old German male who is claiming to have recurring headache and sore throat, and dizziness for the last approximately two weeks to the St…
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The patient further complains of general weakness of the whole body, painful aches all over his body, and itchy eyes, together with a running nose, sore and dry throat. He further complains of coughing. The patient subsequently denies that he has any form of nausea and vomiting. The history of the male patient is that he has been experiencing severe cold and nose blockage since birth. This shows that the patient has been having this problem ever since he was young. Further evidence shows that he has been under medication for the past years. He further claims that the drugs that he is been administered has been giving him difficulties during feeding and moreover during sleep. The patient further has a history of diabetes which he inherited from his parents. This diabetes has led to the lowering of his immune system response and the slow healing of wounds. This is manifested by the presence of the non - healing wounds on his right leg. ROS: Diabetes. Head: The patient claims of severe and recurring headaches. ENT: The patient complains of severe pain and discomfort during eating and also when talking on his throat. Eyes: The patient experiences sore and itchy eyes. He further experiences blurred vision due to the presence of tears on his eyes. Cardio: The patient complains of pain in the chest while breathing and coughing. ...
The patient complains of a recurring and severe headache and sore throat. Allergies: The patient is not experiencing any form of allergy towards dust, cold, or drugs. Medications: The patient is under the medication of diabetes that he inherited from his parents. -Acetaminophen drug -Tylenol -Ibuprofen (Advil and Motrin) -Cough syrup -Other diabetes drugs PMH: -Diabetes -Wounds that take time to heal -Severe fever -Chills Past surgical hx: The patient has never undergone any form of surgical operations. Family hx: The patient has diabetes that he inherited from his parents. Social hx: The patient is married. Have three children; one son and two daughters. He denies that he uses drugs, but he smokes and also drinks alcohol. Objectives: Vitals: HR: 71, BP: 118/71, RR: 21, T: 103.0 oral Physical exam: The patient has a blood group of O+ (positive). He has unclear speech, and uses a lot of energy to walk. Cardio: The patient has a regular rhythm and rate. Resp: The bilateral breath of the patient is not very clear because of sore throat and nose blockage. Thus, he is having difficulty in breathing. Skin: Dry, warm, the nose and the cheeks are pink in color. The patient also has flushed skin. Abd: Soft and non - distended. Lymph: There is presence of palpated lymph nodes under the armpits and other locations of the body. Stool for OC: Negative Labs (1/4/12) – pre transfusion: HGB: 7.9, HCT: 25.6, WBC: 12, PLT: 469, RBC: 2.21, MCV: 87, ALBUMIN: 2.0, PRE – ALBUMIN: 20.1, GLOBULIN: 5.0, IRON: 27 Labs (1/10/12) – post transfusion: HGB: 10.6, HCT: 30.9, WBC: 10, PLT: 430, RBC: 4.21, MCV: 84, RDW: 15.3, RETIC COUNT: 1.7, BUN: 29, CR: 1.12, GFR: 43. 2D Cardiac Echo (10/09/11) EF: 50 – 60% MVP ENT
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(SOAP Notes 1 & 2 Essay Example | Topics and Well Written Essays - 2500 Words)
“SOAP Notes 1 & 2 Essay Example | Topics and Well Written Essays - 2500 Words”, n.d. https://studentshare.org/nursing/1394879-soap-notes.
ist states with public hospitals -Restructure in the system was hoped to improve quality, clarity, effectiveness, and accountability -New agreements require reports on performance in exchange for increased funding -Hoped to solve problems of preventable diseases, gap in life expectancy between indigenous and non-indigenous people, and wait times -NHHRC released a June 2009 final report on health care—proposed that the Commonwealth Government assume full responsibility for funding of primary health care Nicola Roxon – Minister for Health and Ageing who reports directly to the Prime Minister Ten Key Elements of a future Australian health system: 1.
Other potential causal variables are elevated defective esophageal clearance and intra-abdominal pressure. The quantity and absorption of bile acids, proteolytic enzymes, and refluxed gastric acids are among the indicators of the degree of esophageal impairment.
Indeed, the presentation offers significant insight into the world of business and the best business conduct in order to survive in a highly competitive world. This means that one ought to be extremely meticulous when it comes to their career and business choice, as passion is everything.
This may go on for days and even months.
Some people just find themselves looking forward to going home or finding a television set when the "time" comes for their favourite soap opera. It seems that a day is incomplete without them being able to look and get the latest about the lives of their favourite characters.
As in the case of television series like The X Files which have cult followings, soap operas also form a distinctly identifiable genre. Soaps, as they are popularly known, cater to a particular section of society and utilize the social identities of their target audiences to create televised realities which echo - or seem to echo - the lives and longings of their protagonists.
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.
According to the research findings it can therefore be said that despite the fact that the SOAP note may present itself as a redundant method of communication and source of information, it is just as important as the SBAR chart because oftentimes, what other people observe are different from what the attending health care professional observes.
1 Finding suggestive of Ovarian cyst (620.2), diagnosis supported by /confirmed by radiographic imaging of . Ovarian cyst(s) occur mostly in young women and produce adnexal pain. The cysts may be palpable, late cycle (corpus luteum) cysts. Ovarian cysts
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