Our Services

Get 15% Discount on your First Order

[rank_math_breadcrumb]

soap 9

 This is a  69-year-old male with PMH of HTN, HDL 

CC:


SUBJECTIVE:

S: This is a 69-year-old male with PMH of HTN, HDL, CVA/stroke in 2018 with a left-sided weakness and speech impairment presents to the clinic s/p hospitalization 10/15/24 to 10/23/24. Pt has Doppler evidence of Right lower limb artery occlusion in the superficial femoral artery. Patients complain of cramps in the right leg. 7/10 pain. The patient is still struggling with speech. He denies experiencing headaches, dizziness, blurry vision, shortness of breath, chest pain, or palpitations.

CT abdomen showed:- bilateral renal cysts measuring up to 6.8cm in the left upper pole.- enlarged prostate

– degenerative changes in L4-L5. He has 3 hours of home care,

MRI: Acute ischemic infarction involving Left cerebral hemispheric anterior, anterolateral, and posterior cortical border zones. Multiple old infarcts. No acute intracranial hemorrhage, ECHO: EF: 65-70 mg


OBJECTIVE:


Vital Signs:
Ht(without shoes)
165 cm (5’5”). Wt. (dressed) 77.11kg (170 lbs.) (BMI: 29.1 kg/m2) BP 132/88 mmHg (right arm seated); 135/89 mmHg (left arm, seated); with wide cuff. Heart rate (HR) 75 bpm and regular. Respiratory rate (RR) 18 bpm. Temperature (oral) 97.6°F, Spo2: 100% Room air.

make changes when necessary





Eyes;
Vision 20/20 in both eyes. Visual fields full by confrontation. Conjunctive pink; sclera white. Pupils 4 mm constricting to 2 mm. PERRLA. EOMI. Disc margins sharp, without hemorrhage, exudate. No arteriolar narrowing or A-V nicking.


Ears:
 Ear canal clear bilaterally. TM clear bilaterally; bilaterally Ear good cone of light. The cone of light is at 5 o’clock in the right ear and 7 o’clock in the left ear. Rinne test: Positive bilaterally (AC > BC). Weber midline: No lateralization. Mastoid process: No tenderness noted bilaterally.


Nose

 Mucosa pink, septum midline. No sinus tenderness. No polyps, turbinate intact, and there is no evidence of bleeding.


Mouth: 
Oral mucosa pink. The dentition is good. Tongue midline. Tonsils 1+. Pharynx without exudates. 


Neck:
 Neck Supple. Trachea midline. Thyroid isthmus is palpable, lobes not felt.


Lymph Nodes:
 No cervical, axillary, or epitrochlear nodes. 


Thorax and Lungs:
  Thorax Symmetric with good expansion. Lungs resonant on percussion. Breath sounds vesicular with no added sounds. Diaphragms descend 4 cm bilaterally.


Cardiovascular:
 Regular rate and rhythm, heart rate 96 bpm. Crisp S1 and S2. At the base, S2 is louder than S1. At the apex, S1 is louder than S2. There are no murmurs or extra sounds.




-Musculoskeletal
 Muscle or joint pain, stiffness, arthritis, gout, backache. If present, describe the location of affected joints or muscles, any swelling, redness, pain , tenderness, stiffness, weakness, or limitation of motion or activity; include timing of symptoms (e.g., morning or evening), duration, and any history of trauma. Neck or low back pain. Joint pain with systemic symptoms such as fever, chills, rash, anorexia, weight loss, or weakness. 


Abdomen:
soft, non-tender + BS no guarding

Diagnostics:
Obtained before the diagnosis, examples: would be CBC or BMP, CXR or TSH etc.



Laboratory Tests:

Assessment:



Plan:

Any diagnostics ordered/planned (this would be diagnostics needed)

· Pharmacologic and Nonpharmacologic: The patient was prescribed Polymyxin B/Trimethoprim solution one drop q 4 hours while awake
x7 days. (also enter quantity # here if controlled substance or antibiotics)

pharmacologic

·

Medications:

Amlodipine besylate 10 mg tablet daily

Aspirin 81mg chewable tablet one tab daily

Clopidogrel 12.5 mg

Losartan 100 mg

Pantoprazole 10mg

Rosuvastatin 20 mg tab, one tab daily

Eliquis 2.5 mg tablet

follow up with Dr Nahata Vascular on 11/20/24 at Brookhaven.

RTC in 3 weeks pain assessment, might need pain management



Education:

·

Procedures: None at this time

·
Education:
non-pharmacologic



Follow-up:

Referral:

NOTE

· Any diagnostics ordered/planned (this would be diagnostics needed)

· The patient was prescribed Polymyxin B/Trimethoprim solution one drop q 4 hours while awake
x7 days. (also enter quantity # here if controlled substance or antibiotics)

NO REFERENCE NEEDED

Share This Post

Email
WhatsApp
Facebook
Twitter
LinkedIn
Pinterest
Reddit

Order a Similar Paper and get 15% Discount on your First Order

Related Questions

Nursing 611 assignment 1

Identify a current research problem related to advanced nursing practice that is of interest to you. Include WHY this is a problem. (Limit response to no more than 3 sentences). Develop a research question to provide information about the research problem.

WK 7 BLOG

Innovative Informatics Tools and Applications to Clinical Practice New technology and tools will undoubtedly shape nursing practice.  “Research suggests that between 8% and 16% of nursing time is spent on non-nursing activities and tasks that should be delegated to others” (Robert, 2019). As a result, new innovations may minimize the

WK 6 DIs Resp

Digital Health: Mobile Devices, Wearables, Telehealth, Telemedicine Preparing for her run, Susan tightened her fitness watch on her wrist. After experiencing and having received treatment for a heart arrhythmia, Susan was encouraged to wear the watch that not only would alert her if she experienced an irregular heartbeat, but the

Nursing

  Create a concept map of a mental health diagnosis using one of the mental health scenario case studies presented in this section of the course.

NIH assign

This week, reflect on what you learned from the NIH materials about protecting the rights of human research participants. Discuss at least  two of the following in your paper: · Describe the circumstances that influenced the need for a policy to protect human research subjects. Give examples of specific ways human

CJP

Clinical Judgement Plan Instructor: DATE Care Provided and UNIT: Student Name Clinical Judgement Plan West Coast University Professor Name Date OB History GTPAL: Prenatal Panel Blood Type/Rh: GBS: Hep B: HIV: Rubella: RPR: Chlamydia: Gonorrhea: HSV: Delivery Summary Gestational age: Delivery Type: Delivery Time: Postpartum Day: Placenta Delivery Time: Lacerations/Episiotomy:

Nursing nursing homework

Goals and Objectives for Teaching Project Topic/Goal: Managing new hypertension diagnosis in Hispanic patients living in Miami, nutrition management, lifestyle changes, preventing health risk through community education and support. To develop the Goals and Objectives for the Community Teaching project, follow the following steps: 1. The goal or aim of

Health Promotion Discussion Week 1 Reply to Peer 2

One of the most pressing yet often invisible public health issues today is intimate partner violence and caregiver abuse of older or vulnerable adults. These forms of violence occur in private spaces, often behind closed doors, and many victims are unable or afraid to ask for help. Healthy People 2030

Optimizing Population Health Through Community Practice assessment 2

Research a selected local, national, or global nonprofit organization or government agency to determine how it contributes to public health and safety improvements, promotes equal opportunity, and improves the quality of life within the community. Submit your findings in a 3–5 page report. Many organizations work to better local and

Questions

Instructions: For this discussion, please complete the following: Review the assigned chapters in Polit and Beck (2017): i.e., chapters 18-20. Identify five different facts or pieces of information that pertain to the topic. Construct 3 multiple choice questions based on the information in the text and post these questions to

Commh

Who are the clients in Community Health nursing? What government resources might they be eligible for? What agencies are responsible for those resources? 

Issue of Advanced Practice

Identify a current research problem related to advanced nursing practice that is of interest to you. Include WHY this is a problem. (Limit response to no more than 3 sentences). Develop a research question to provide information about the research problem.

Legislative Agenda

Personal Legislative Agenda · Review the Personal Legislative Agenda and Action Plan Exemplar to demonstrate how you will construct your Personal Legislative Agenda for the state and federal proposed legislation.   · Review the Personal Legislative Agenda and Action Plan Exemplar to determine which approach might work best for advancing your

WK 6 RESP

Digital Health: Mobile Devices, Wearables, Telehealth, Telemedicine Preparing for her run, Susan tightened her fitness watch on her wrist. After experiencing and having received treatment for a heart arrhythmia, Susan was encouraged to wear the watch that not only would alert her if she experienced an irregular heartbeat, but the

WK4 QUESTION HP-213

COMPLETE QUESTIONS  Thumbnails/thumbnail.png 1) Codes 20900–20938 for grafts (or implants) are reported when __________ tissue (originating in the patient’s body) is obtained through separate skin or fascial incisions. Responses allogenous allogenous rhytid rhytid osteogenesis osteogenesis autogenous autogenous 2) A patient suffered a traumatic complete amputation of the left forearm in

WK4 ASSIGNMENT HP-213

COMPLETE IN DETAIL Thumbnails/thumbnail.png Coding for Musculoskeletal Services You are a new medical coder who works for an Orthopedic medical practice. Patients are often seen for fractures or dislocations which require either a cast or splint. A common patient encounter may be for the application of a long-arm split. Apply

WK4 ASSIGNMENT RESUME HP-213

COMPLETE IN DETAIL Thumbnails/thumbnail.png Career Corner – Resume In a previous class, you did a mock interview with tutor.com. This week’s activity is to create a current resume. Submit it to Tutor.com for their review. Submit the finalized resume to this week’s assignment drop box. Use the Live Tutoring link on the

WK4 QUESTIONS HP-212

COMPLETE QUESTION BY FILLING IN THE BLANK Thumbnails/thumbnail.png 1) Sepsis due to E. coli. Responses A41.4 A41.50 A41.51 A41.9 2) Metastatic carcinoma from the lung. Responses D49.9, C80.1 D49.9, C34.90 C79.9, D49.1 C34.90, C79.9 3) ype 2 diabetes mellitus with diabetic macular edema and retinopathy, right eye, resolved following treatment. Responses