Soap Notes

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J.L. SOAP NOTE
Subjective
J.L. is a 63-year-old white female who presented to the ER with right lower extremity pain and swelling with subsequent changes to the skin, including formation of bullous ulcers. She had blistering over the past four days that started to enlarge. The doctor prescribed her Bactrim. Erythema, swelling, and pain progressively got worse. She denies any fever or chills. PMH:
COPD, Hypertension, Diabetes mellitus, Osteoporosis, Fibromyalgia, Osteoarthritis, Morbid obesity Allergies: Morphine Nubain

Social History: Patient denies smoking and alcohol use. She is disabled and lives at home with her husband.
Objective
Medications: Clonazepam 0.5 mg by mouth once daily Simvastatin 10 mg by
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For pathogens with an MIC ≤1 mcg/mL, the minimum trough concentration should be 15 mcg/mL to meet target AUC/MIC of ≥40 h. Toxic: >80 mcg/mL
Invanz
a. Monitor periodic renal, hepatic, and hematopoietic assessment during prolonged therapy; neurological function b. Renal dosage adjustment should be based on i. Clcr >30 mL/minute/1.73 m2: No adjustment required ii. Clcr ≤30 mL/minute/1.73 m2 and ESRD: 500 mg/day c. Counsel on diarrhea 3. Start IV diflucan a. Administer loading dose of 50-400 mg, then administer 400 mg every day for 3 days? (lexi comp: duration and dosage depend on location and severity of infection) b. Counsel on angioedema, headache, rash and dizziness c. Monitor: Periodic liver function tests (AST, ALT, alkaline phosphatase) and renal function tests,
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