StudentShare
Contact Us
Sign In / Sign Up for FREE
Search
Go to advanced search...

Problem based SOAP notes for three patients - Essay Example

Cite this document
Summary
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…
Download full paper File format: .doc, available for editing
GRAB THE BEST PAPER93% of users find it useful
Problem based SOAP notes for three patients
Read Text Preview

Extract of sample "Problem based SOAP notes for three patients"

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.

GoutSubjective 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 pages Read More
Cite this document
  • APA
  • MLA
  • CHICAGO
(“Problem based SOAP notes for three patients Essay”, n.d.)
Problem based SOAP notes for three patients Essay. Retrieved from https://studentshare.org/miscellaneous/1534353-problem-based-soap-notes-for-three-patients
(Problem Based SOAP Notes for Three Patients Essay)
Problem Based SOAP Notes for Three Patients Essay. https://studentshare.org/miscellaneous/1534353-problem-based-soap-notes-for-three-patients.
“Problem Based SOAP Notes for Three Patients Essay”, n.d. https://studentshare.org/miscellaneous/1534353-problem-based-soap-notes-for-three-patients.
  • Cited: 0 times

CHECK THESE SAMPLES OF Problem based SOAP notes for three patients

Effective Hand Hygiene in Clinical Settings

This is because when the health practitioners have contaminated hands, the patients are put at risk of developing infections.... Currently, hand hygiene is recognized to be important in providing quality care to the patients and is included in the standards for hospital accreditation.... The cleaning can either be done with water or another liquid or soap.... Hand disinfection refers to the use of antiseptic solution, either medicated soap or alcohol to clean the hand....
7 Pages (1750 words) Literature review

Record Keeping in Patient Care

This paper “Record Keeping in Patient Care” aims at understanding the importance of accurate record keeping and its role in extending high quality health care to patients.... These include, focus on the extended primary care team as the prime means of healthcare delivery, improved keeping of patients' records and communication between professionals, and greater recognition of consumers' wishes for good quality and well coordinated care (Department of Health, 2003)....
25 Pages (6250 words) Coursework

Audit report: hand washing in a hospital ward setting

In this situation, good hand hygiene of staff, patients and visitors is again essential in order to avoid the conversion of the infection into a full-size SARS epidemic (Health Protection Agency, 2005).... It could quickly become a problem after undergoing surgery, suffering a serious illness or in cases where a compromised immune system is present.... It could quickly become a problem after undergoing surgery, suffering a serious illness or in cases where a compromised immune system is presenHand washing is the single most important procedure for preventing the contraction and spread of infections in hospitals....
11 Pages (2750 words) Essay

Good Documentation is Good Communication Nursing Care Plans

The document should be updated daily in the progress notes by the responsible registered nurse.... Documentation is any communicable material, which is used to explain some attributes of an object, system or process.... Many a times, technical or medical writing skills are taught to the person who seeks to take responsibility of writing documents and it will be discussed in this paper....
9 Pages (2250 words) Essay

Benefits of Alcohol Based Gel over Soap Based Scrub in Preventing Nosocomial Infection in Care Facility

16 Pages (4000 words) Essay

Nutritional Support for Patients with Advanced/End-Stage Dementia

Dementia is one of the single… patients with advanced or end death stage dementia are the most delicate in the sense that balancing between their nutritional wellbeing and their health is a tricky affair.... One of the single most critical issues Care of dementia patients is of essence while taking into consideration about their nutritional wellbeing.... alnutrition is a problem that face dementia patients.... In a number of health facilities, doctors use the tubes to help feed the patients....
12 Pages (3000 words) Essay

Hand Washing in Hospitals

In this situation, good hand hygiene of staff, patients and visitors are essential.... However, it could quickly become a problem after undergoing surgery, suffering a serious illness or in cases where a compromised immune system is present.... The paper “Hand Washing in Hospitals” looks at infections contracted in hospitals, which are an everyday occurrence....
12 Pages (3000 words) Assignment

Plain Soap in Dealing With Bacteria

This scientific report "Plain soap in Dealing With Bacteria" demonstrates that Antibacterial Soaps and hand sanitizers that contain alcohol are as ineffective as plain soap on the bacterial properties.... he recent marketing and promotion of antibacterial everything have transformed the consumer thought that antibacterial soap is necessary to get rid of all the bacteria on the hands.... Anti-bacterial agents have been pumped by manufacturers into soap for several decades, although, it has been within the last decade that anti-bacterial soaps have been widely used (Ngo, 2005)....
8 Pages (2000 words) Report
sponsored ads
We use cookies to create the best experience for you. Keep on browsing if you are OK with that, or find out how to manage cookies.
Contact Us