NRNP 6540 Week 7 Gynecological Disorders Soap Note

NRNP 6540 Week 7 Gynecological Disorders Soap Note essay assignment

NRNP 6540 Week 7 Gynecological Disorders Soap Note essay assignment

Case Study 1:

R.B. 95-year-old, white male, currently living in a skilled nursing facility (SNF)

Chief complaint: “My urine is really red.”

HPI: On Wednesday (2 days ago) the patient was brought to your clinic by his son and complained that his urine appeared to be bright red in color. You ordered labs, urinalysis, culture, and sensitivity, and the results are below.

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Medications: Tamsulosin 0.4 mcg, 2 capsules daily, Aspirin 325 mg daily, Atorvastatin 10 mg 1 tablet daily, Donepezil 10 mg 1 tablet PO QHS, Metoprolol 25 mg 0.5 mg tablet every 12 hours, Acetaminophen 500 mg 1 tablet BID

Code status: DNR  Regular diet, pureed texture, honey-thickened liquids

Vitals: BP 122/70, HR 66, Temp 98.0 F, Resp 18, Pulse ox 98%

PMH: Cognitive communication deficit, pneumonitis due to inhalation of food and vomit, dysphagia, R-side hemiplegia and hemiparesis past ischemic CVA, moderate vascular dementia, malignant neoplasm of prostate, new-onset atrial fibrillation (12/2019), DVT on left lower extremity, gross hematuria

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