Nursing

Subjective Data:

Subjective Data: Chief Complaint: “I cannot stop to drink water and to pee, I need to see my labs” Symptom analysis/HPI: The patient is 56 years old female who complaining of she cannot stop to drink water and to pee. Patient noticed the problem started 1 month ago and sometimes it is accompanied by anxious […]

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Miami Regional University

(Student Name) Miami Regional University Date of Encounter: Preceptor/Clinical Site: Clinical Instructor:   Soap Note # Main Diagnosis Diabetes Mellitus type 2   PATIENT INFORMATION Name: Mr. ET Age: 56-year-old Gender at Birth: Female Gender Identity: Female Source: Patient Allergies: Penicillins Current Medications: · Multi-Vitamin Centrum Silver · Lisinopril 10 mg daily · PMH: HTN

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What is the Christian view of the nature of human persons, and which theory of moral status is it compatible with?

What is the Christian view of the nature of human persons, and which theory of moral status is it compatible with? Based on “Case Study: Fetal Abnormality” and other required topic study materials, write a 750-1,000-word reflection that answers the following questions: What is the Christian view of the nature of human persons, and which theory

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· Provide with nutrition/dietary information.

· Provide with nutrition/dietary information. · Provide with nutrition/dietary information. · Daily blood pressure monitoring at home twice a day for 7 days, keep a record, bring the record on the next visit with her PCP · Instruction about medication intake compliance. · Education of possible complications such as stroke, heart attack, and other problems.

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Assessment

Assessment Essential (Primary) Hypertension (ICD10 I10): Given the symptoms and high blood pressure (156/92 mmhg), classified as stage 2. Once the organic cause of hypertension has been ruled out, such as renal, adrenal or thyroid, this diagnosis is confirmed. Differential diagnosis: Ø Renal artery stenosis(ICD10 I70.1) Ø Chronic kidney disease(ICD10 I12.9) Ø Hyperthyroidism (ICD10 E05.90)

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MUSCULOSKELETAL

MUSCULOSKELETAL: Denies falls or pain. Denies hearing a clicking or snapping sound. Skin: No change of coloration such as cyanosis or jaundice, no rashes or pruritus. Objective Data CONSTITUTIONAL: Vital signs: Temperature: 98.5 °F, Pulse: 87, BP: 159/92 mmhg, RR 20, PO2-98% on room air, Ht- 6’4”, Wt 200 lb, BMI 25. Report pain 0/10.

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CONSTITUTIONAL: Denies fever or chills. Denies weakness or weight loss

ROS: CONSTITUTIONAL: Denies fever or chills. Denies weakness or weight loss. NEUROLOGIC: Headache and dizzeness as describe above. Denies changes in LOC. Denies history of tremors or seizures. HEENT: HEAD: Denies any head injury, or change in LOC. Eyes: Denies any changes in vision, diplopia or blurred vision. Ear: Denies pain in the ears. Denies

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Symptom analysis/HPI:

Symptom analysis/HPI: The patient is 65 years old male who complaining of episodes of headaches and on 3 different occasions blood pressure was measured, which was high (159/100, 158/98 and 160/100 respectively). Patient noticed the problem started two weeks ago and sometimes it is accompanied by dizziness.He states that he has been under stress in

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