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Here is the SOAP note with the findings copied into the appropriate sections: S: Reports no nausea or vomiting. Sleeping OK. O: T: 36°C P: 94/min R: 18/min BP: 157/86 mmHg. General appearance: fair-looking. A: 1. Chronic kidney disease, stage V, favor diabetic nephropathy, C/W uremic symptoms 2. Anemia P: 1. Check U/A 2. Arrange kidney echo 3. Continue EPO, ferrous, pentoxifylline 4. Follow-up in 4 weeks

Author

nathalie c. rodriguez

Language

EN