4. Systematically document patient's problem utilizing SOAP/FARM format CASE CC "I feel tired, nauseated, and constipated." HPI Jane Lopez is a 42-year-old woman who presents to the outpatient dialysis center for her routine HD treatment. She has ESRD secondary to hypertension and has been on HD for 4 years. She has a failed AV fistula and graft and is currently dialyzed via central venous catheter. She has an upcoming appointment with the vascular surgeon to reevaluate her HD access. She also frequently leaves HD 30-60 minutes early against medical advice. PMH ESRD secondary to HTN Anuria HTN Anemia Secondary hyperparathyroidism H/O gestational diabetes 12 years ago GERD PSH Cesarean section 12 years ago Tubal ligation 10 years ago AV fistula creation 5 years ago (failed) AV graft creation 3 years ago (failed) FH Father died of MI at age 60. Mother deceased due to breast cancer. No siblings. Has a 12-year-old son in good health. SH Married, lives with husband and a 12-year-old son. Occasional social alcohol use. Smokes 1/2 ppd (decreased from one ppd x 10 years). Denies caffeine consumption. ROS Complains of feeling tired and weak over the past several weeks. Reports some swelling in feet and lower legs. Also reports constipation, nausea, and heartburn. Meds Furosemide 80 mg PO daily Metoprolol tartrate 50 mg PO BID Lisinopril 20 mg PO daily
4. Systematically document patient's problem utilizing SOAP/FARM format CASE CC "I feel tired, nauseated, and constipated." HPI Jane Lopez is a 42-year-old woman who presents to the outpatient dialysis center for her routine HD treatment. She has ESRD secondary to hypertension and has been on HD for 4 years. She has a failed AV fistula and graft and is currently dialyzed via central venous catheter. She has an upcoming appointment with the vascular surgeon to reevaluate her HD access. She also frequently leaves HD 30-60 minutes early against medical advice. PMH ESRD secondary to HTN Anuria HTN Anemia Secondary hyperparathyroidism H/O gestational diabetes 12 years ago GERD PSH Cesarean section 12 years ago Tubal ligation 10 years ago AV fistula creation 5 years ago (failed) AV graft creation 3 years ago (failed) FH Father died of MI at age 60. Mother deceased due to breast cancer. No siblings. Has a 12-year-old son in good health. SH Married, lives with husband and a 12-year-old son. Occasional social alcohol use. Smokes 1/2 ppd (decreased from one ppd x 10 years). Denies caffeine consumption. ROS Complains of feeling tired and weak over the past several weeks. Reports some swelling in feet and lower legs. Also reports constipation, nausea, and heartburn. Meds Furosemide 80 mg PO daily Metoprolol tartrate 50 mg PO BID Lisinopril 20 mg PO daily
Phlebotomy Essentials
6th Edition
ISBN:9781451194524
Author:Ruth McCall, Cathee M. Tankersley MT(ASCP)
Publisher:Ruth McCall, Cathee M. Tankersley MT(ASCP)
Chapter1: Phlebotomy: Past And Present And The Healthcare Setting
Section: Chapter Questions
Problem 1SRQ
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