Review of Systems (ROS) CONSTITUTIONAL: Denies fever or chills. Denies weakness or weight loss. NEUROLOGIC: Headache and dizziness 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 […]
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
(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
Miami Regional University Read More »
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
Soap note of Diabetes Mellitus Soap note of Diabetes Mellitus:free plagiarismAPA style Place Your Order Here!
Soap note of Diabetes Mellitus Read More »
· 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.
· Provide with nutrition/dietary information. Read More »
Non-Pharmacologic treatment: · Weight loss · Healthy diet (DASH dietary pattern): Diet rich in fruits, vegetables, whole grains, and low-fat dairy products with reduced content of saturated and trans l fat · Reduced intake of dietary sodium: <1,500 mg/d is optimal goal but at least 1,000 mg/d reduction in most adults · Enhanced intake of
Non-Pharmacologic treatment Read More »
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)
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.
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
CONSTITUTIONAL: Denies fever or chills. Denies weakness or weight loss Read More »