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

SOAP notes 1 & 2 - Essay Example The patient further complains of general weakness of the whole body, painful aches all over his body, and itchy eyes, together with a running nose, sore 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 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 slow 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 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 never 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 th e 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 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) – post transfusion: HGB: 10.6, HCT: 30.9, WBC: 10, PLT: 430, 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% MVP ENT