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

SOAP notes 1 & 2 - Essay ExampleThe diligent hike up complains of general weakness of the whole body, painful aches all over his body, and itchy eyes, together with a running nose, disturbed 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 only 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 bearing 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 neer 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 on that point 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) stigmatise transfusion HGB 10.6, HCT 30.9, WBC 10, PLT 430, RBC 4.21, MCV 84, RDW 15.3, RETIC COUNT 1.7, B UN 29, CR 1.12, GFR 43. 2D Cardiac Echo (10/09/11) EF 50 60% MVP ENT