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soap 123 end.docx - IPE case SOAP Departments Pharmacy and...

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IPE case SOAP Departments: Pharmacy and Nutrition Spring-2016 Pharmacy students: Nutrition students: Khadijah Mohammed 201000321 Aala Elamin 201102358 Fatima Maraghi 201001093 Athiya Yusuf 201104062 Alya Babiker 20100362 Huda Al-hadhromi 201002889 Hana Dawalbeat 201103965 Date: Friday, September 29, 2017
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September 29, 2017 Pt: ED Age: 71 y o Reason for visit: exacerbation of Diabetes Mellitus Type II S: Mrs. Elieen Douglas is 71 years African American Homemaker female who has a complain of cut on her foot, happened over 2 months ago and has not healed. She also thinks that she doesn’t see well, she has troubles reading newspapers; complain from bladder infections and slight tingling and numbness in her feet. Her education level is less than high school (10th grade). She lives with her 80-years sister and takes care of her. She lives in a low-income apartment. She was diagnosed with T2DM, and on admission her BG was 325 mg/dl. Tx: surgical debridement of wound, sliding scale insulin, 1200kcal diet, DM self-management education. She has a medical history of hypertension and medications include Capoten 50mg twice/day and she doesn’t smoke O: She had a documented frequent bladder infection in the past. She has hypertension and on Capoten 50mg twice/day .
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