BASELINE SOAPING OF INDEX PATIENT

Problem #1: Anemia

S> The patient was seen and examined with the following subjective complaints:
Weakness
No night sweats
Dizziness
Adequate urine output
Poor appetite
Good bowel movement
O> Patient is conscious, coherent, not in cardiorespiratory distress with the following vital signs
BP: 150/80 CR: 80
RR: 18
Temp: 37.2oC

Pink palpebral conjunctiva, white sclera, no naso-aural discharge, no tonsillopharyngeal
congestion

Neck in midline, supple, no mass, no cervical lymphadenopathy

Symmetric chest expansion, no retractions, clear breath sounds , good air entry

Adynamic precordium, normal rate, regular rhythm, no murmur

Flabby abdomen, soft, normoactive bowel sounds

No active dermatoses

Neurologic evaluation: intact memory, intact cranial nerves

No babinski reflex, (-) brudzinski, (-) nuchal rigidity
NMH
5/5
5/5

Sensory
5/5
5/5

DTR
5/5
5/5

A> Anemia
P> For CBC, PBS, Retic count determination, and Thyroid Function Test
Ferrous Sulfate 200mg BID for 2 months

Problem #2: Hypertension

S> The patient was seen and examined with the following subjective complaints:
Weakness
Poor appetite
Dizziness
No night sweats
Nape pain
Adequate urine output
No chest pain
Good bowel movement
No headache

O> Patient is conscious, coherent, not in cardiorespiratory distress with the following vital signs
BP: 150/80 CR: 84
RR: 18
Temp: 37.2oC

Pink palpebral conjunctiva, white sclera, no naso-aural discharge, no tonsillopharyngeal
congestion

Neck in midline, supple, no mass, no cervical lymphadenopathy

Symmetric chest expansion, no retractions, clear breath sounds , good air entry

Adynamic precordium, normal rate, regular rhythm, no murmur

Flabby abdomen, soft, normoactive bowel sounds

No active dermatoses

Neurologic evaluation: intact memory, intact cranial nerves

No babinski reflex, (-) brudzinski, (-) nuchal rigidity
NMH
5/5
5/5

Sensory
4/4
5/5

DTR
5/5
5/5

B> Hypertension
P> Diet for age, low salt, low fat diet
For hypertension work up: FBS, lipid profile, BUN, crea, ECG, CXR, urinalysis, CBC,
SGPT, Na, K
For cervical Xray
Losartan 50mg/ hydrochlorothiazide 12.5mg 1 tab once a day
Continue BP monitoring

Problem #3: Hypothyroidism

S> The patient was seen and examined with the following subjective complaints:
Weakness
No night sweats
Dizziness
Adequate urine output
Poor appetite
Good bowel movement

O> Patient is conscious, coherent, not in cardiorespiratory distress with the following vital signs
BP: 150/80 CR: 84
RR: 18
Temp: 37.2oC

Pink palpebral conjunctiva, white sclera, no naso-aural discharge, no tonsillopharyngeal
congestion

Neck in midline, supple, no mass, no cervical lymphadenopathy

Symmetric chest expansion, no retractions, clear breath sounds , good air entry

Adynamic precordium, normal rate, regular rhythm, no murmur

Flabby abdomen, soft, normoactive bowel sounds

No active dermatoses

Neurologic evaluation: intact memory, intact cranial nerves

No babinski reflex, (-) brudzinski, (-) nuchal rigidity
NMH
5/5
5/5

Sensory
4/4
5/5

DTR
5/5
5/5

C> Hypothyroidism
P> For Thyroid Function Test (TSH, FT3, FT4)
Levothyroixine 1.6 ug/kg body weight

BASELINE SOAPING OF FAMILY MEMBERS

Problem #1: HYPERTENSION
S> The patient was seen and examined with the following subjective complaints:
No weakness
Good appetite
No dizziness
No night sweats
No nape pain
Adequate urine output
No chest pain
Good bowel movement
No headache
O> Patient is conscious, coherent, not in cardiorespiratory distress with the following vital signs
BP: 150/80 CR: 64
RR: 20
Temp: 37oC

Pink palpebral conjunctiva, white sclera, no naso-aural discharge, no tonsillopharyngeal
congestion

Neck in midline, supple, no mass, no cervical lymphadenopathy

Symmetric chest expansion, no retractions, vesicular breath sound, with crackles on right
and left lower lung fields

Adynamic precordium, normal rate, regular rhythm, no murmur

Flabby abdomen, soft, normoactive bowel sounds

No active dermatoses

Neurologic evaluation: intact memory, intact cranial nerves

No babinski reflex, (-) brudzinski, (-) nuchal rigidity
NMH ??
5/5
5/5

Sensory
5/5
5/5

DTR
5/5
5/5

D> Hypertension
P> Low salt, low fat diet
Continue Amlopdipine 10mg, 1 tab once a dat
Continue Aspirin 80mg, 1 tab once a day
BP monitoring

Problem #2: Community Acquired Pneumonia

S> The patient was seen and examined with the following subjective complaints:
Productive coughing
Good appetite
Colds
No night sweats
No fever
Adequate urine output
No nausea
Good bowel movement
No vomiting
O> Patient is conscious, coherent, not in cardiorespiratory distress with the following vital signs
BP: 150/80 CR: 64
RR: 20
Temp: 37oC

Pink palpebral conjunctiva, white sclera, no naso-aural discharge, no tonsillopharyngeal
congestion

Neck in midline, supple, no mass, no cervical lymphadenopathy

Symmetric chest expansion, no retractions, vesicular breath sound, with crackles on right
and left lower lung fields

Adynamic precordium, normal rate, regular rhythm, no murmur

Flabby abdomen, soft, normoactive bowel sounds

No active dermatoses

Neurologic evaluation: intact memory, intact cranial nerves

No babinski reflex, (-) brudzinski, (-) nuchal rigidity
NMH ??
5/5
5/5

Sensory
5/5
5/5

DTR
5/5
5/5

E> Community Acquired Pneumonia- Low Risk

P> Cefuroxime axetil, 500mg, 1 tab 2x a day for 7 days
Carbocisteine 500mg, 1 tab 3x a day for ??
Increase oral water intake