SOAP notes 1 & 2 Essay Example | Topics and Well Written Essays - 2500 words

SOAP notes 1 & 2 - Essay ExampleThe long-suffering moreover complains of general weakness of the whole body, painful aches all over his body, and itchy eyes, together with a running schnoz, sore and dry throat. He further complains of coughing. The patient by and by denies that he has any form of nausea and vomiting. The history of the male patient is that he has been experiencing horrendous arctic 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 downstairs(a) 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 decelerate 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 occur headaches. ENT The patient complains of severe pain and discomfort during eating and as well as 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 historic surgical hx The patient has never undergone any form of surgical operations. Family hx The patient has diabetes that he inherited from his parents. sociable 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 store group of O+ (positive). He has unclear speech, and uses a lot of energy to walk. Cardio The patient has a continual 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 blood transfusion HGB 7.9, HCT 25.6, white corpuscle 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 43 0, 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% most valuable player ENT