NP SOAP note: hypertension and diabetes

CHE6301 Columbia Southern Community Health Worker Case Study Questions
November 10, 2021
St Petersburg College Substance Abuse and Elderly Research Paper
November 10, 2021

70yr old african american (Ruthie) 3 month follow up for HTN, DM. Complaints of: wake up w/ HA x2 weeks (‘pressure ring’ around head), light headed, crazy dreams, stress, congestion x1day, nausea, productive cough, runny/stuffy nose, sore throat, 1+ ankle edema

tylenol helps w/ HA

vitals: 120/72, pulse 76, temp 98.5F, 5’7 286lbs A1C; 5.2 BMP no abnormalities

no social hx, no ETOH, non-smoker, depression no family hx

patient Hx: HA, reflux, memory loss (referred to neuro/hasn’t seen yet), back pain surgical hx: RTK, LTK, tubal ligation

medications: Benicar 40mg daily, Januvia 100 daily

negative for chest pain, SOB, vomiting, diarrhea, lungs clear, no wounds to feet

need: differential dx, action/plan for 3-6 months out

dx: sinusitis, recommend warm cloth over eyes/sinus, recommendations for stress relief, f/u with neuro

rx: flonase

(Add what you feel needed)

"Looking for a Similar Assignment? Order now and Get 10% Discount. Discount Code - "Newclient"!

Hi there! Click one of our representatives below and we will get back to you as soon as possible.

Chat with us on WhatsApp