Mr. Smith is a 71 year old male who presents with anorexia, nausea

Question Answered step-by-step Mr. Smith is a 71 year old male who presents with anorexia, nauseaand vomiting.  No stool for 5 days.  Symptoms are described as beginning several days ago, and patient reports symptoms have been worsening since that time. Patient states abdominal pain 5/10 especially after eating. Past medical history is significant for DM type 2 (controlled with oral meds, diet, and exercise), depression, and history of gastric ulcer.  Objective: VS: Temp 101oF, BP 95/60, HR 94, RR 20, SpO2 93% on 2L/min by NC. Admit weight: 218 lbs. Exam: General: A&Ox3, appears somewhat uncomfortable. HEENT: PERRLA, conjunctiva pink, sclera icteric, oropharynx mildly erythematous Neck: Supple, no adenopathy Lungs: clear, decreased sounds in all lobesHeart: regular rhythm, no murmurs, or gallops Abdomen: rigid, tender, hypoactive bowel soundsExtremities: 2+ pulses, trace edema in ankles, no rashes noted Neuro: unsteady gait, normal speech, sensations to light touch throughout   Create a SOAP note for your patient SOAP Please as per case study  and give more information especially the  PLAN  Health Science Science Nursing NRSE 2030 Share QuestionEmailCopy link Comments (0)