Soap Notes

Mrs Gale is a 70 year old widow and retired unskilled worker. The patient lives alone and relies on her son to provide basic care,

2/10/2016, 1600, Vital Signs: BP 140/85 P132 RR32 Temp 102.2 SpO2 85% on 2 liter by nasal cannula. Jacquline Catanzaro is 45 years old female on disability admitted to Medical Unit Hospital. Sister with patient. Reason to admit is can’t breathe. Diagnosis is 30 year of asthma exacerbation, psychiatric schizophrenia, obesity, pneumonia and herniated disc. Smokes 40 packs year. Drinks 2 pots of coffee a day. Drinks 3 beers each day. Frequency ED visits and hospitalization dependence on rescue inhaler. Patient refuses wear nasal cannula because of worry that it contains poison. Patient has a long history of stopping taking psychiatric medication and asthma medications. Patient has isolated herself from others. Sister is only caregiver. Neuro

Dosages of the drug vary from one extreme to another based upon the patients needs.

Susan is a 78 year old widowed lady who was admitted to a medical ward following an episode of coffee brown vomiting and breathlessness. Susan has a past medical history of chronic

A is an 87 year old women, with a long history of health troubles including chronic kidney disease, congestive heart failure, coronary artery disease, a pacemaker insertion for her atrial fibrillation, type 2 diabetes, dyslipidemia, colon cancer, breast cancer, mild cognitive impairment and most recently paranoid psychosis.

BB’s skin presents as pink, warm and dry. No obvious signs or symptoms of abnormal bruising or lesions present however, the patient states that the skin has of late has

HISTORY AND PHYSICAL EXAMINATION_______________________ Patient Name: Chapman Robert Kinsey Patient ID: 110589 Room No.: 322-B Date of Admission: 23 February ---Admitting Physician: Martha C. Eaton, MD, Geriatrics Chief Complaint: Admitted from Dr. Max Hirsch’s office due to deep ulcer on left toe. Admitting Diagnoses 1. Severe peripheral vascular disease, status post deep ulcer on left toe. Rule out thrombolysis. The patient was admitted to a regular floor. Condition is serious. 2. ALLERGY TO PENICILLIN, which puts patient into anaphylactic shock. 3. Continue with home medications. DETAILS OF PRESENT ILLNESS: Mr. Kinsey is an 87-year-old white gentleman with history of (1) Chronic atrial fibrillation, on Coumadin. (2) Chronic deafness,

Patient is a high school counselor. He participates in physical activities by running 2 to 3 times a week, playing golf, and volunteering at a nursing home. The patient is married with one daughter and one son. He does not use tobacco and periodically drinks at

issues with behavioral as well as not being punctual for her arrival to work. client was diagnosed with

4. Exposure 3 repeat step 3 w/o including the saline bags (used as a control).

Pt is a 84 year old Cascasion female living with her husband in their home. Husband reported the Pts Alzhemers has be pergresing for the last 8-9 years. Pt had open heart surgery in 2012, which contributed to the memory loss decline and increasing level of Alzhemer symtoms, husband verbalized. Husband reports they have been married for 19 years. Pt has a sister living Florda, two daughters living in Texas and Wyoming and one son in New York. The children stay in contact with them every other day. Pt reports she worked as a RN at the VA Hospital in New Mexico. Pt is not independent in the home without the husbands assistance. Pt does ambulate well in the home, but does have a walker in needed. Husband assists the Pt all her ADL's in the home and drives her to the store and for MD appointments. Husband currently suffers from Hemochromatosis (too much iron in one's body). Husband reports he manages well with his illness while taking care of Pt at the sametime. Husband reports the Pt's Alzehmers level appears to be stable at this time, but is quite forgetful at times and needs his assistance. Husband said they are managing

7. the minimize injection-site discomfort, not mare than how many vaccine injections will be given on the same day?

She was diagnosed in December of 1997. Overall, she is reported to be in stable health and has no known allergies to food or medications. Paula does not have a history of seizures. She is being monitored for high cholesterol, however her mother indicates Paula is not taking the medication and instead is exercising regularly and monitoring food intake as a means to reduce cholesterol levels to a normal range. Paula does not take prescribed medication and taking a variety of natural supplements. She has a history of sleep insomnia and will stay up late perseverating on past events, when this occurs, her mother will administer 12mg melatonin to help her sleep. Paula was recently diagnosed with sleep apnea following a sleep study completed by (______) on (___). Results indicated she stopped breathing 10 times per hour during her study and it was recommended she use a continuous positive airway pressure (CPAP) device when sleeping or taking a nap. She is on a regular diet and requires supervision to monitor food intake. Paula has a preference for eat, take food, and if able to will consume in excess. Mother reports that Paula is monitored by physicians and dentist on a regular basis and receives medical coverage through

b.ii. The dosage will depend on the age, weight, and other health issues of the person.

Patient also, has history of hypertension, GERD, morbid obesity, anemia, and depression. She reported that the past few months, she has been feeling very weak and overall generalized deconditioning. Her ability to care for herself including her activities of daily living (ADLs), and her basic physical needs (like bathing, grooming, ambulation, meal preparation, transportation, errands, and housekeeping), had decreased, and cannot consistently carry them out.