David Kim - Case NOTE 29.pdf
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SOAP Note Patient with UTI
United State University
FNP xxx: Common Illness Across the Lifespan -Clinical Practicum
Dr. xxxx
SOAP Note Patient with UTI
ID: L.U. a female patient presented to the clinic accompany by self, patient is a reliable historian.
Client’s Initials: L.U
Age :65 years.
Race: African American
Gender: Female
Date of Birth: 08
Insurance: BlueCross BlueShield .
Marital Status: Married
Subjective: “ I have been having pain and burning during urination for two weeks now and the pain goes to my lower abdomen, and I have been unable to hold urine, I now urinate on myself because I can no longer hold it until I get to the bathroom”.
CC: Pain and burning during urination.
HPI:
Patient stated symptoms began within the past two weeks and have worsened over the past seven days. The patient complains of severe pain and burning sensation during urination that radiates to lower abdomen, with urgency. The urine is cloudy and has a foul smell odor. After attempting to pass urine, the pain subsides for a little while, yet it reoccurs. Patient states that she has been sexually active only with the same partner for the past 15 years. On assessment patient reports pain of 8 /10 on pain scale. Patient denies having blood in urine, fever, headache, shortness of breath or chest pain at the moment.
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Constitutional: Patient states she is in good state of health she denies headache , chest pain weakness fever chills, weight loss or gain.
Eyes: Denies double vision, change in vision factors, or blurry vision.
Ears/Nose/Mouth/Throat: denies sore throat, hearing issues, or nose congestion.
Cardiovascular: denies any kind of orthopnea, rapid heart rate, palpitations, or chest pain.
Pulmonary: Denies
Gastrointestinal: c/o moderate to severe pain in the abdominal area.
Genitourinary: acknowledged presence of increase in urgency and frequency of urination. Major pain while urinating for the past ten days.
Musculoskeletal: Denies any kind of pain
Integumentary & breast: Denies issues
Neurological: Denies issues
Psychiatric: Denies any kind of depression or mood swing
Endocrine: Denies having any problem
Hematologic/Lymphatic: Denies
Allergic/Immunologic: No Known allergy
Past Medical History:
· Medical problem list: patient denies having any major illnesses and only reports headaches and sometimes common seasonal allergy or cold.
· Denies history of chronic medical problems with father or mother.
· Preventative care: None indicated
· Surgeries: Denies
· Hospitalizations: Denies
· LMP: Patient states she do have a 28 days menstrual cycle and the last cycle was 2 weeks ago. She has had three pregnancies and three cesarean section.
Allergies: No known food or drug allergy
· Medications: Patient takes only Centrum vitamins and sometimes Tylenol for headache. Family History: Patient’s mother has hypertension that she manages by taking daily medication and exercising. The patient’s father has hypertension too a ...
12SOAP Note Patient with UTIUnited State
1
2
SOAP Note Patient with UTI
United State University
FNP xxx: Common Illness Across the Lifespan -Clinical Practicum
Dr. xxxx
SOAP Note Patient with UTI
ID: L.U. a female patient presented to the clinic accompany by self, patient is a reliable historian.
Client’s Initials: L.U
Age :65 years.
Race: African American
Gender: Female
Date of Birth: 08
Insurance: BlueCross BlueShield .
Marital Status: Married
Subjective: “ I have been having pain and burning during urination for two weeks now and the pain goes to my lower abdomen, and I have been unable to hold urine, I now urinate on myself because I can no longer hold it until I get to the bathroom”.
CC: Pain and burning during urination.
HPI:
Patient stated symptoms began within the past two weeks and have worsened over the past seven days. The patient complains of severe pain and burning sensation during urination that radiates to lower abdomen, with urgency. The urine is cloudy and has a foul smell odor. After attempting to pass urine, the pain subsides for a little while, yet it reoccurs. Patient states that she has been sexually active only with the same partner for the past 15 years. On assessment patient reports pain of 8 /10 on pain scale. Patient denies having blood in urine, fever, headache, shortness of breath or chest pain at the moment.
ROS
Constitutional: Patient states she is in good state of health she denies headache , chest pain weakness fever chills, weight loss or gain.
Eyes: Denies double vision, change in vision factors, or blurry vision.
Ears/Nose/Mouth/Throat: denies sore throat, hearing issues, or nose congestion.
Cardiovascular: denies any kind of orthopnea, rapid heart rate, palpitations, or chest pain.
Pulmonary: Denies
Gastrointestinal: c/o moderate to severe pain in the abdominal area.
Genitourinary: acknowledged presence of increase in urgency and frequency of urination. Major pain while urinating for the past ten days.
Musculoskeletal: Denies any kind of pain
Integumentary & breast: Denies issues
Neurological: Denies issues
Psychiatric: Denies any kind of depression or mood swing
Endocrine: Denies having any problem
Hematologic/Lymphatic: Denies
Allergic/Immunologic: No Known allergy
Past Medical History:
· Medical problem list: patient denies having any major illnesses and only reports headaches and sometimes common seasonal allergy or cold.
· Denies history of chronic medical problems with father or mother.
· Preventative care: None indicated
· Surgeries: Denies
· Hospitalizations: Denies
· LMP: Patient states she do have a 28 days menstrual cycle and the last cycle was 2 weeks ago. She has had three pregnancies and three cesarean section.
Allergies: No known food or drug allergy
· Medications: Patient takes only Centrum vitamins and sometimes Tylenol for headache. Family History: Patient’s mother has hypertension that she manages by taking daily medication and exercising. The patient’s father has hypertension too a ...
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Chief complaint:
“ I have chronic constipation, incomplete defecation and abdominal bloating” for past 2 years.
HPI:
M.C. a 46-year-old hispanic female presents to the GI-Motility clinic for complaint of chronic constipation, incomplete defecation and abdominal bloating. She has pmhx of DM-type 2, IBS-Constipation, Tubular Adenoma.
She also indicates that she has noticed that her symptoms are worsening for past 3 months. She has associated her symptoms with abdominal bloating, straining and incomplete defecation.
She has tried Miralax one packet po daily for at least 8 weeks and it has not relieved her symptoms.
Denies associated symptoms of hematochezia, melena, hemoptysis, abdominal pain, fever, chills, pain or any other symptoms.
PMH:
Diabetes Mellitus, type 2
Constipation, chronic-IBS
Surgeries: None
Allergies
:
Penicillin
Vaccination History:
She receives an annual flu shot. Last flu shot was this year
Social history:
High school graduate, married and no children. He drinks one 4-ounce glass of red wine daily. He is a former smoker that stopped 3 years ago.
Family history:
Both parents are alive. Father has history of DM type 2, Tinea Pedis.
mother alive and has history of atopic dermatitis, tinea corporis and tinea pedis.
ROS:
Constitutional: Negative for fever. Negative for chills.
Respiratory: No Shortness of breath. No Orthopnea
Cardiovascular: + 1 pitting leg edema. + Varicose veins.
Skin: + rash crusted white in feet and inter-digit in feet.
Psychiatric: No anxiety. No depression.
Physical examination:
Vital Signs
Height: 5 feet 5 inches Weight: 140 pounds BMI: 31 obesity, BP 110/70 T 98.0 po P 80 R 22, non-labored
HEENT
: Normocephalic/Atraumatic, PERRL, EOMI; No teeth loss seen. Gums no redness.
NECK
: Neck supple, no palpable masses, no lymphadenopathy, no thyroid enlargement.
LUNGS
: Lungs clear bilaterally. Equal breath sounds. Symmetrical respiration. No respiratory distress.
HEART
: Normal S1 with S2 during expiration. Pulses are 2+ in upper extremities. No edema.
ABDOMEN
: No abdominal distention. Nontender. Bowel sounds + x 4 quadrants. No organomegaly. Normal contour; No palpable masses.
GENITOURINARY
: No CVA tenderness bilaterally. GU exam deferred.
MUSCULOSKELETAL
: Slow gait but steady. No Kyphosis.
SKIN: +Dryness, No open lesions. +Dry crusts in sole of feet. + moist crust in between toes.
PSYCH
: Normal affect. ...
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Some proposed mechanisms for acid-peptic disease and gastric ulcer disease include:
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2. A thorough history, physical exam, and basic lab tests are needed to evaluate for potential physiological or pathological causes of unexplained weight loss. Further testing like imaging may be needed depending on initial findings.
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This case presentation describes a 35-year-old female who presented with generalized swelling over her body for 20 days and abdominal pain for 1 day. Her history and examination findings were consistent with hypothyroidism, nephrotic syndrome, and systemic lupus erythematosus. Laboratory tests confirmed Hashimoto's thyroiditis, lupus nephritis with nephrotic range proteinuria, and positive ANA, anti-dsDNA, and anti-thyroglobulin antibodies. She was started on prednisone and thyroxine therapy and admitted for further management including a renal biopsy.
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12SOAP Note Patient with UTIUnited State
1
2
SOAP Note Patient with UTI
United State University
FNP xxx: Common Illness Across the Lifespan -Clinical Practicum
Dr. xxxx
SOAP Note Patient with UTI
ID: L.U. a female patient presented to the clinic accompany by self, patient is a reliable historian.
Client’s Initials: L.U
Age :65 years.
Race: African American
Gender: Female
Date of Birth: 08
Insurance: BlueCross BlueShield .
Marital Status: Married
Subjective: “ I have been having pain and burning during urination for two weeks now and the pain goes to my lower abdomen, and I have been unable to hold urine, I now urinate on myself because I can no longer hold it until I get to the bathroom”.
CC: Pain and burning during urination.
HPI:
Patient stated symptoms began within the past two weeks and have worsened over the past seven days. The patient complains of severe pain and burning sensation during urination that radiates to lower abdomen, with urgency. The urine is cloudy and has a foul smell odor. After attempting to pass urine, the pain subsides for a little while, yet it reoccurs. Patient states that she has been sexually active only with the same partner for the past 15 years. On assessment patient reports pain of 8 /10 on pain scale. Patient denies having blood in urine, fever, headache, shortness of breath or chest pain at the moment.
ROS
Constitutional: Patient states she is in good state of health she denies headache , chest pain weakness fever chills, weight loss or gain.
Eyes: Denies double vision, change in vision factors, or blurry vision.
Ears/Nose/Mouth/Throat: denies sore throat, hearing issues, or nose congestion.
Cardiovascular: denies any kind of orthopnea, rapid heart rate, palpitations, or chest pain.
Pulmonary: Denies
Gastrointestinal: c/o moderate to severe pain in the abdominal area.
Genitourinary: acknowledged presence of increase in urgency and frequency of urination. Major pain while urinating for the past ten days.
Musculoskeletal: Denies any kind of pain
Integumentary & breast: Denies issues
Neurological: Denies issues
Psychiatric: Denies any kind of depression or mood swing
Endocrine: Denies having any problem
Hematologic/Lymphatic: Denies
Allergic/Immunologic: No Known allergy
Past Medical History:
· Medical problem list: patient denies having any major illnesses and only reports headaches and sometimes common seasonal allergy or cold.
· Denies history of chronic medical problems with father or mother.
· Preventative care: None indicated
· Surgeries: Denies
· Hospitalizations: Denies
· LMP: Patient states she do have a 28 days menstrual cycle and the last cycle was 2 weeks ago. She has had three pregnancies and three cesarean section.
Allergies: No known food or drug allergy
· Medications: Patient takes only Centrum vitamins and sometimes Tylenol for headache. Family History: Patient’s mother has hypertension that she manages by taking daily medication and exercising. The patient’s father has hypertension too a ...
12SOAP Note Patient with UTIUnited State
1
2
SOAP Note Patient with UTI
United State University
FNP xxx: Common Illness Across the Lifespan -Clinical Practicum
Dr. xxxx
SOAP Note Patient with UTI
ID: L.U. a female patient presented to the clinic accompany by self, patient is a reliable historian.
Client’s Initials: L.U
Age :65 years.
Race: African American
Gender: Female
Date of Birth: 08
Insurance: BlueCross BlueShield .
Marital Status: Married
Subjective: “ I have been having pain and burning during urination for two weeks now and the pain goes to my lower abdomen, and I have been unable to hold urine, I now urinate on myself because I can no longer hold it until I get to the bathroom”.
CC: Pain and burning during urination.
HPI:
Patient stated symptoms began within the past two weeks and have worsened over the past seven days. The patient complains of severe pain and burning sensation during urination that radiates to lower abdomen, with urgency. The urine is cloudy and has a foul smell odor. After attempting to pass urine, the pain subsides for a little while, yet it reoccurs. Patient states that she has been sexually active only with the same partner for the past 15 years. On assessment patient reports pain of 8 /10 on pain scale. Patient denies having blood in urine, fever, headache, shortness of breath or chest pain at the moment.
ROS
Constitutional: Patient states she is in good state of health she denies headache , chest pain weakness fever chills, weight loss or gain.
Eyes: Denies double vision, change in vision factors, or blurry vision.
Ears/Nose/Mouth/Throat: denies sore throat, hearing issues, or nose congestion.
Cardiovascular: denies any kind of orthopnea, rapid heart rate, palpitations, or chest pain.
Pulmonary: Denies
Gastrointestinal: c/o moderate to severe pain in the abdominal area.
Genitourinary: acknowledged presence of increase in urgency and frequency of urination. Major pain while urinating for the past ten days.
Musculoskeletal: Denies any kind of pain
Integumentary & breast: Denies issues
Neurological: Denies issues
Psychiatric: Denies any kind of depression or mood swing
Endocrine: Denies having any problem
Hematologic/Lymphatic: Denies
Allergic/Immunologic: No Known allergy
Past Medical History:
· Medical problem list: patient denies having any major illnesses and only reports headaches and sometimes common seasonal allergy or cold.
· Denies history of chronic medical problems with father or mother.
· Preventative care: None indicated
· Surgeries: Denies
· Hospitalizations: Denies
· LMP: Patient states she do have a 28 days menstrual cycle and the last cycle was 2 weeks ago. She has had three pregnancies and three cesarean section.
Allergies: No known food or drug allergy
· Medications: Patient takes only Centrum vitamins and sometimes Tylenol for headache. Family History: Patient’s mother has hypertension that she manages by taking daily medication and exercising. The patient’s father has hypertension too a ...
PELVIC INFLAMMATORY DISEASE (PID)
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This presentation is prepared as a case based discussion.
References include American Academy of Family Physicians AAFP
I WOULD LIKE TO DEDICATE SPECIAL THANKS TO
DR ALI AL KHALAF FOR REVISING THIS MATERIAL
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3. It identifies diagnostic tests that should have been performed to confirm or rule out potential diagnoses like gastroenteritis, Crohn's disease, ulcerative colitis, and kidney stones.
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RH negative case presentation.pptx
- This is a case presentation of a 24-year-old woman, Mrs. Ranjani, who is 34 weeks and 1 day into her pregnancy. She has an Rh negative blood type while her husband's is Rh positive, making this an Rh incompatible pregnancy.
- Her past obstetric history includes one full-term vaginal delivery. During her current pregnancy she received regular antenatal checkups and her tests have been normal. She is being referred for a tertiary care opinion due to the Rh incompatibility.
- On examination, she appears well with normal vital signs. The fetus is in a cephalic presentation with a heart rate of 146 beats per minute. Further tests and monitoring are planned to
For the following Case Study, as follow is Discussion Question
For the following Case Study, as follow is Discussion Question: As an NP student, needs to determine the medications for constipation.
According to the ACC/AHA Guidelines, what medication should this patient be prescribed for constipation? Write her complete prescriptions using the prescription writing format.
Support with 1 journal no older than 5 years.
Week 7: DISCUSSION QUESTION IN DISCUSSION BOARD
Gastroenterology-Motility Case Study
ACC/AHA Guidelines
PLEASE USE THIS MEDICATION FOR THE CASE STUDY: LUBIPRISTONE 24 MCG TWO TIMES A DAY.
Case study sample:
Chief complaint:
“ I have chronic constipation, incomplete defecation and abdominal bloating” for past 2 years.
HPI:
M.C. a 46-year-old hispanic female presents to the GI-Motility clinic for complaint of chronic constipation, incomplete defecation and abdominal bloating. She has pmhx of DM-type 2, IBS-Constipation, Tubular Adenoma.
She also indicates that she has noticed that her symptoms are worsening for past 3 months. She has associated her symptoms with abdominal bloating, straining and incomplete defecation.
She has tried Miralax one packet po daily for at least 8 weeks and it has not relieved her symptoms.
Denies associated symptoms of hematochezia, melena, hemoptysis, abdominal pain, fever, chills, pain or any other symptoms.
PMH:
Diabetes Mellitus, type 2
Constipation, chronic-IBS
Surgeries: None
Allergies
:
Penicillin
Vaccination History:
She receives an annual flu shot. Last flu shot was this year
Social history:
High school graduate, married and no children. He drinks one 4-ounce glass of red wine daily. He is a former smoker that stopped 3 years ago.
Family history:
Both parents are alive. Father has history of DM type 2, Tinea Pedis.
mother alive and has history of atopic dermatitis, tinea corporis and tinea pedis.
ROS:
Constitutional: Negative for fever. Negative for chills.
Respiratory: No Shortness of breath. No Orthopnea
Cardiovascular: + 1 pitting leg edema. + Varicose veins.
Skin: + rash crusted white in feet and inter-digit in feet.
Psychiatric: No anxiety. No depression.
Physical examination:
Vital Signs
Height: 5 feet 5 inches Weight: 140 pounds BMI: 31 obesity, BP 110/70 T 98.0 po P 80 R 22, non-labored
HEENT
: Normocephalic/Atraumatic, PERRL, EOMI; No teeth loss seen. Gums no redness.
NECK
: Neck supple, no palpable masses, no lymphadenopathy, no thyroid enlargement.
LUNGS
: Lungs clear bilaterally. Equal breath sounds. Symmetrical respiration. No respiratory distress.
HEART
: Normal S1 with S2 during expiration. Pulses are 2+ in upper extremities. No edema.
ABDOMEN
: No abdominal distention. Nontender. Bowel sounds + x 4 quadrants. No organomegaly. Normal contour; No palpable masses.
GENITOURINARY
: No CVA tenderness bilaterally. GU exam deferred.
MUSCULOSKELETAL
: Slow gait but steady. No Kyphosis.
SKIN: +Dryness, No open lesions. +Dry crusts in sole of feet. + moist crust in between toes.
PSYCH
: Normal affect. ...
Chronic Diarrhea
Chronic Diarrhea
references include the American Academy of Family Physicians AAFP
Special Thanks to my colleague Hadi Al Qurain for his participation in preparing this presentation
Obg case review of ectopic Pregnancy
A 30-year-old woman, gravida 2,Para1 ,Living 1 And abortion 0 presented to emergency department for left abdominal pain at 7weeks and 3 days.
Case Study Report on PIH and Severe Pre eclampsia
it is a case study report on PIH and Severe Pre eclampsia
I did when I was posted on Kist Medical TEaching Hospital for Midwifery Practicum
Prepared by:
Rashmi Regmi
B Sc Nursing
Manmohan Memorial Institute Of health Sciences
CASE PRESENTATIONS;.pptx
Some proposed mechanisms for acid-peptic disease and gastric ulcer disease include:
- Excessive acid secretion leading to direct damage of the gastric mucosa. Proton pump inhibitors are effective treatments by reducing acid production.
- Infection with Helicobacter pylori, which can increase gastric acid production and impair mucosal defenses. Eradication of H. pylori is an important treatment strategy.
- Nonsteroidal anti-inflammatory drug (NSAID) use, like the ibuprofen in this case, which inhibit prostaglandin synthesis and impair mucosal defenses against acid exposure.
- Stress and smoking can also increase acid secretion and impair mucosal defenses, pre
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David Kim - Case NOTE 29.pdf
- 1. WRITING SUB-TEST: NURSING TIME ALLOWED: READING: 5MINUTES WRITING: 40MINUTES Read the case notes and complete the writing task which follows. Assume that today’s date is April 1, 2023 You are a nurse in charge in St. Mark’s Hospital; you are now referring a patient David Kim, 27 years old to the Gastroenterologist for further care. Read the case note below and complete the writing task which follows. Name: David Kim Age: 27 years old Gender: Male Patient Details: Social Background: Accountant Diagnosis: Acute infectious diarrhea with suspected bacterial etiology. NOTES:
- 2. Medical History: Past medical history- lactose intolerance. Present Complaints: Abdominal pain and diarrhea- past week. No h/o recent travel or contact with sick individuals. Assessment: General examination: Uncomfortable due to abdominal pain. Vital signs - normal limits, Diffuse abdominal tenderness Hyperactive bowel sounds. No signs of organomegaly or palpable masses. Investigations: stool analysis- presence of WBC and occult blood Blood tests- leukocytosis and hypokalemia. Medical progress: Prescribed antibiotics for suspected bacterial infection. Monitored closely for any changes in his symptoms and the response to treatment. Nursing Management: • Intravenous Antibiotics Advised to increase his fluid intake, avoid solid foods until the diarrhea subsides. Plan: Gastroenterologist opinion for appropriate choice of antibiotics and dietary management.
- 3. Using the information in the case notes, write a letter to Gastroenterologist, outlining the case and requesting for urgent assessment and treatment. Address the letter to Gastroenterologist, St. Mark’s Hospital, Watford Rd, Harrow HA1 3UJ, UK. In your answer: Expand the relevant notes into complete sentences Do not use note form Use letter format The body of the letter should be approximately 180-200 word Writing Task: