Documents

SOAP

Description
guidelines in charting
Categories
Published
of 5
All materials on our website are shared by users. If you have any questions about copyright issues, please report us to resolve them. We are always happy to assist you.
Related Documents
Share
Transcript
  BASELINE SOAPING OF INDEX PATIENT Problem #1: Anemia S> The patient was seen and examined with the following subjective complaints: Weakness No night sweats Dizziness Adequate urine output Poor appetite Good bowel movement O> Patient is conscious, coherent, not in cardiorespiratory distress with the following vital signs BP: 150/80 CR: 80 RR: 18 Temp: 37.2 o C    Pink palpebral conjunctiva, white sclera, no naso-aural discharge, no tonsillopharyngeal congestion    Neck in midline, supple, no mass, no cervical lymphadenopathy    Symmetric chest expansion, no retractions, clear breath sounds , good air entry    Adynamic precordium, normal rate, regular rhythm, no murmur    Flabby abdomen, soft, normoactive bowel sounds    No active dermatoses    Neurologic evaluation: intact memory, intact cranial nerves    No babinski reflex, (-) brudzinski, (-) nuchal rigidity NMH Sensory DTR 5/5 5/5 5/5 5/5 5/5 5/5 A>   Anemia P> For CBC, PBS, Retic count determination, and Thyroid Function Test Ferrous Sulfate 200mg BID for 2 months  Problem #2: Hypertension S> The patient was seen and examined with the following subjective complaints: Weakness Poor appetite Dizziness No night sweats Nape pain Adequate urine output No chest pain Good bowel movement No headache O> Patient is conscious, coherent, not in cardiorespiratory distress with the following vital signs BP: 150/80 CR: 84 RR: 18 Temp: 37.2 o C    Pink palpebral conjunctiva, white sclera, no naso-aural discharge, no tonsillopharyngeal congestion    Neck in midline, supple, no mass, no cervical lymphadenopathy    Symmetric chest expansion, no retractions, clear breath sounds , good air entry    Adynamic precordium, normal rate, regular rhythm, no murmur    Flabby abdomen, soft, normoactive bowel sounds    No active dermatoses    Neurologic evaluation: intact memory, intact cranial nerves    No babinski reflex, (-) brudzinski, (-) nuchal rigidity NMH Sensory DTR 5/5 4/4 5/5 5/5 5/5 5/5 B>   Hypertension P> Diet for age, low salt, low fat diet For hypertension work up: FBS, lipid profile, BUN, crea, ECG, CXR, urinalysis, CBC, SGPT, Na, K For cervical Xray Losartan 50mg/ hydrochlorothiazide 12.5mg 1 tab once a day Continue BP monitoring  Problem #3: Hypothyroidism S> The patient was seen and examined with the following subjective complaints: Weakness No night sweats Dizziness Adequate urine output Poor appetite Good bowel movement O> Patient is conscious, coherent, not in cardiorespiratory distress with the following vital signs BP: 150/80 CR: 84 RR: 18 Temp: 37.2 o C    Pink palpebral conjunctiva, white sclera, no naso-aural discharge, no tonsillopharyngeal congestion    Neck in midline, supple, no mass, no cervical lymphadenopathy    Symmetric chest expansion, no retractions, clear breath sounds , good air entry    Adynamic precordium, normal rate, regular rhythm, no murmur    Flabby abdomen, soft, normoactive bowel sounds    No active dermatoses    Neurologic evaluation: intact memory, intact cranial nerves    No babinski reflex, (-) brudzinski, (-) nuchal rigidity NMH Sensory DTR 5/5 4/4 5/5 5/5 5/5 5/5 C>   Hypothyroidism P> For Thyroid Function Test (TSH, FT3, FT4) Levothyroixine 1.6 ug/kg body weight   BASELINE SOAPING OF FAMILY MEMBERS Problem #1: HYPERTENSION S> The patient was seen and examined with the following subjective complaints: No weakness Good appetite No dizziness No night sweats No nape pain Adequate urine output No chest pain Good bowel movement No headache O> Patient is conscious, coherent, not in cardiorespiratory distress with the following vital signs BP: 150/80 CR: 64 RR: 20 Temp: 37 o C    Pink palpebral conjunctiva, white sclera, no naso-aural discharge, no tonsillopharyngeal congestion    Neck in midline, supple, no mass, no cervical lymphadenopathy    Symmetric chest expansion, no retractions, vesicular breath sound, with crackles on right and left lower lung fields    Adynamic precordium, normal rate, regular rhythm, no murmur    Flabby abdomen, soft, normoactive bowel sounds    No active dermatoses    Neurologic evaluation: intact memory, intact cranial nerves    No babinski reflex, (-) brudzinski, (-) nuchal rigidity NMH ?? Sensory DTR 5/5 5/5 5/5 5/5 5/5 5/5 D>   Hypertension P> Low salt, low fat diet Continue Amlopdipine 10mg, 1 tab once a dat Continue Aspirin 80mg, 1 tab once a day BP monitoring
We Need Your Support
Thank you for visiting our website and your interest in our free products and services. We are nonprofit website to share and download documents. To the running of this website, we need your help to support us.

Thanks to everyone for your continued support.

No, Thanks