PracticumExperience SOAP Note
SoapNote
PatientInitials: PKL Age:27 years Gender:Female
Subjective
ChiefComplaint:complains of having escalated hypertension
History ofPresent Illness:27-year-oldfemalediagnosedhaving diabetic ketoacidosis. The patient is most disturbed bynon-proliferative retinopathy coupled with nephrotic syndrome. Sheasserted that she has experienced frequent hypoglycemia coupled withweight gain. As per her assertions, she also has escalatedhypertension (ranging at 172/108 mmHg). She further stipulated thather urinalysis report shows the presence of hyaline and blood cells.Her medical history unravels that she contracted diabeticketoacidosis aged fourteen years. She is currently takingHydrochlorothiazide, 25mg in her 7thweek of medication after undertaking a 2.0 mg/dl creatinine and aretained Intravenouscyclophosphamide on Plaquenil & Prednisone both in her 1stand 4thweek of medication.
Medications:Hydrochlorothiazide, 25mg daily.
Allergies:The patient medical history does not reveal any allergies.
PastMedical History:The patient has had diabetic ketoacidosis ailment for the lastfourteen years. The case study doesn’t reveal any history ofhospitalization.
PastSurgical History:No highlighted surgery operations.
Sexual/ReproductiveHistory:No highlighted key sexual or reproductive aspects.
Personal/SocialHistory:The patient takes a daily 25mg dosage of Hydrochlorothiazide. Duringthe 1stand 4thweek of medication, the patient had undertaken a retained intravenouscyclophosphamide and creatinine at 2.0 mg/dl
ImmunizationHistory:The case study doesn’t reveal any immunization history.
SignificantFamily History:The case study doesn’t reveal any parental or family history
Lifestyle:The case study doesn’t reveal any lifestyle aspects.
Review ofSystems:
General:Thepatient confides of weight gain
Skin:The patient affirms that no rashes or skin sores that have beenexhibited during the ailing period.
OBJECTIVEDATA
PhysicalExam:
Key Signs:Blood pressure of 172/108 mmHg
General:27-year-oldfemale who appears energetic, healthy and in excellent posture
Skin:The client’s skin appears turgor and has uniform complexion.
HEENT:
Head-seems symmetrical.
Eyes-theeyes have a completely transparent cornea coupled by a white sclera.
Ears-appear to be in the right posture and no lesions or visible palpablemasses.
Nose:her nose appears symmetrical with no evidence of nasal discharges orvisible lesions.
Tongue:The patients tongue appears centrally positioned.
Assessment
Primarydiagnosis:Escalated hypertension
DifferentialDiagnosis:Severe hypoglycemia coupled with weight gain. The patients’urinalysis report unravels 2+ blood and 3+ proteins. In addition, herurine shows blood cells and hyaline. However, further medicalassessment is essential so as to confirm the diagnosis.
Plan
The optimumobjective is to cut down the rate of hypertension and leverage thesymptoms of diabetic ketoacidosis.
TreatmentPlan:The patient can undergo a fluidreplacement either orally or intravenously. The patient can undergoan electrolyte replacement as well (electrolytes may encompasschlorides and potassium). Lastly, the patient can undertake anInsulin therapy.
HealthPromotion:take part in regular exercise and take balanced diet with extremelyminimal fat and cholesterol
DiseasePrevention:Maintain a steady daily diet.
REFLECTION
One of theperfect options to advance the health care quality is via thedeployment of soap notes. The patient case study acquainted me withan awareness that soap notes avails a rapid and effective mechanismfor tracking the patients’ medical progress. From a clinicalperspective, I’m now furnished with the information that patientsailing from diabetes ketoacidosis have intricate symptoms whichjeopardize their general health and wellbeing. Faced with a congruentscenario, I’ll screen the patients’ medical history at a deeperscrutiny level. I would also enquire concerning the patients familyhistory. I concur with the preceptor based evidence.
REFERENCES
In Byham-Gray,L., In Burrowes, J. D., & In Chertow, G. M. (2014). Nutrition inkidney disease.
In Dunphy, L.M. H., In Winland-Brown, J. E., In Porter, B. O., & In Thomas, D.J. (2015). Primary care: The art & science of advanced practicenursing.
Kopple, J. D.,Massry, S. G., and Kalantar-Zadeh, K. (2013). Nutritional managementof renal disease. London: Academic Press.
Wahlqvist, M.L., Vobecky, J. S., International Union of Nutritional Sciences. &World Health Organization. (1987). Patient problems in clinicalnutrition: A manual. London: J. Libbey.