Practicum - Week 3 SOAP
Note
Walden University
Advanced Practice Care of
Adults
NURS 6540N-4
Dr.
September 23,
2018
, PRACTICUM - WEEK 3 SOAP NOTE 2
Practicum - Week 3 SOAP
Note
Internal Medicine - Admission consultation for medical management and
treatment Patient Initials: P.A. Age: 81 yrs. Sex: Female Race:
Caucasian
SUBJECTIVE
CC: "I'm worried about all these urinary tract infections."
HPI: P.A. is an 81year old female with a recent history of recurrent UTIs, CHF, HTN,
CVA/TIA, COPD with chronic use of O2, and Barrett's esophagus who admitted to the
rehabilitation hospital on 9/7/2018 due to ambulatory dysfunction secondary to urinary
tract infection. The patient initially presented to the ED on 9/6/2018 complaining of back
pain, generalized weakness, and dysuria. She had recently been hospitalized and then
discharged to an acute rehabilitation hospital for UTI and ambulatory dysfunction. She
had completed a course of PO Levaquin one day prior to being discharged home from
rehab. She had been doing well initially, but 3 days prior to presenting to the ED, the
patient developed increasing urinary urgency, dysuria, and back pain. She also noted right
abdominal pain and RLE pain. No nausea or vomiting, no change in bowel movements, no
chest pain or palpitations, SOB, HA or change in vision reported. In ED vital signs were
stable and the patient afebrile. She was subsequently admitted to inpatient status and
started on Levaquin 750mg IV since the last urine culture on 8/19 had grown Klebsiella,
sensitive to Levofloxacin. She remained afebrile with stable vital signs through the
hospitalization. No acute abnormalities were seen on head CT. CXR showed persistent
increased opacity in bilateral lower lungs, could be atelectasis or infiltrates and
additionally persistent hypoinflation of lungs. The patient's clinical disposition gradually
improved, but she continued to have ambulatory dysfunction and generalized
deconditioning.
She was felt to be a good candidate for aggressive inpatient rehabilitation, so she was
referred to HealthSouth Rehabilitation Hospital for comprehensive rehab.
Today, the patient was evaluated in her room at the bedside, sitting up in a chair, O2 NC at
2 l/min. She states she has a good appetite, is moving her bowels and typically takes
MiraLAX at home with applesauce and prune juice to keep her bowels regular. Voiding
without any complaints or concerns, drinking fluids. She is very concerned about her
recurrent UTIs. So far, tolerating rehab therapies. No acute medical concerns reported
otherwise by nursing staff.
Medications:
1.) Coreg 3.125 PO, BID with meals
2.) Lovenox syringe 40mg SC, once a
day 3.) Folvite 1mg PO, once a day
4.) Lasix 20mg PO, once a day
5.) Humalog injection 4 units SC, AC &
HS 6.) Levaquin 750mg IV, Q 24h
Note
Walden University
Advanced Practice Care of
Adults
NURS 6540N-4
Dr.
September 23,
2018
, PRACTICUM - WEEK 3 SOAP NOTE 2
Practicum - Week 3 SOAP
Note
Internal Medicine - Admission consultation for medical management and
treatment Patient Initials: P.A. Age: 81 yrs. Sex: Female Race:
Caucasian
SUBJECTIVE
CC: "I'm worried about all these urinary tract infections."
HPI: P.A. is an 81year old female with a recent history of recurrent UTIs, CHF, HTN,
CVA/TIA, COPD with chronic use of O2, and Barrett's esophagus who admitted to the
rehabilitation hospital on 9/7/2018 due to ambulatory dysfunction secondary to urinary
tract infection. The patient initially presented to the ED on 9/6/2018 complaining of back
pain, generalized weakness, and dysuria. She had recently been hospitalized and then
discharged to an acute rehabilitation hospital for UTI and ambulatory dysfunction. She
had completed a course of PO Levaquin one day prior to being discharged home from
rehab. She had been doing well initially, but 3 days prior to presenting to the ED, the
patient developed increasing urinary urgency, dysuria, and back pain. She also noted right
abdominal pain and RLE pain. No nausea or vomiting, no change in bowel movements, no
chest pain or palpitations, SOB, HA or change in vision reported. In ED vital signs were
stable and the patient afebrile. She was subsequently admitted to inpatient status and
started on Levaquin 750mg IV since the last urine culture on 8/19 had grown Klebsiella,
sensitive to Levofloxacin. She remained afebrile with stable vital signs through the
hospitalization. No acute abnormalities were seen on head CT. CXR showed persistent
increased opacity in bilateral lower lungs, could be atelectasis or infiltrates and
additionally persistent hypoinflation of lungs. The patient's clinical disposition gradually
improved, but she continued to have ambulatory dysfunction and generalized
deconditioning.
She was felt to be a good candidate for aggressive inpatient rehabilitation, so she was
referred to HealthSouth Rehabilitation Hospital for comprehensive rehab.
Today, the patient was evaluated in her room at the bedside, sitting up in a chair, O2 NC at
2 l/min. She states she has a good appetite, is moving her bowels and typically takes
MiraLAX at home with applesauce and prune juice to keep her bowels regular. Voiding
without any complaints or concerns, drinking fluids. She is very concerned about her
recurrent UTIs. So far, tolerating rehab therapies. No acute medical concerns reported
otherwise by nursing staff.
Medications:
1.) Coreg 3.125 PO, BID with meals
2.) Lovenox syringe 40mg SC, once a
day 3.) Folvite 1mg PO, once a day
4.) Lasix 20mg PO, once a day
5.) Humalog injection 4 units SC, AC &
HS 6.) Levaquin 750mg IV, Q 24h
