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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• Dosage too high
• Needs additional
monitoring
Adherence
• Patient knowledge
• Financial impact
• Failure to receive therapy
.
C. Prioritized problem list: Create a list of patient's
healthcare problems and/or drug-therapy problems.
Prioritized them according to severity. Briefly describe the
problem based on your assessment of their severity.
Priority Health Care Problems Description
IV. PLANNING: This section is where the final treatment
plan is given for each of the active problems as justified in the
assessment.
Pharmacist's Care Plan
Health care
problem
Goals Endpoints
Recommendation
(Drug or Non-drug)
Monitoring
Parameters (frequency
of monitoring)
II. Targeted Questions
1. List the possible causes of CKD in this patient.
2. Mrs. Lopez would like a kidney transplant but must first
quit smoking to become eligible for transplant. Create a
smoking cessation plan for her.
Transcribed Image Text:• Dosage too high • Needs additional monitoring Adherence • Patient knowledge • Financial impact • Failure to receive therapy . C. Prioritized problem list: Create a list of patient's healthcare problems and/or drug-therapy problems. Prioritized them according to severity. Briefly describe the problem based on your assessment of their severity. Priority Health Care Problems Description IV. PLANNING: This section is where the final treatment plan is given for each of the active problems as justified in the assessment. Pharmacist's Care Plan Health care problem Goals Endpoints Recommendation (Drug or Non-drug) Monitoring Parameters (frequency of monitoring) II. Targeted Questions 1. List the possible causes of CKD in this patient. 2. Mrs. Lopez would like a kidney transplant but must first quit smoking to become eligible for transplant. Create a smoking cessation plan for her.
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
Transcribed Image Text: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
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