TYPHON SOAP
[text name="age"] y.o. with ESRD on [text name="dialysis"] presents for pre-kidney transplant cardiac evaluation. PMH history includes[checkbox name="PMH" value="HTN|DM|HLD|obesity|HLD|depression|anxiety|gout|arthritis"] [select name="1" value="He|She"] denies fever, fatigue, headaches, dizziness, cough, SOB or DOE, chest pain, palpitations, N/V/D/C, polyphagia, polydipsia, polyuria, joint pains, balance issues, rashes, wounds, anxiety, depression. Positive for[text area name="variable_1" default=""]Neuro: CN 2-12 intact, AOx3; HEENT: deferred; RESP: BBS clear and equal, respirations even & unlabored; CV: RRR, PMI @ 5th ICS, no M/R/G, no peripheral edema; ABD: SNTND, + BS x4, no hepatosplenomegaly; GU: deferred; MS: FROM intact, steady gait; SKIN: color appropriate for ethnicity, warm, dry, no rashes/wounds [text name="variable_1" default=""] PSYCH: appropriate mood and affect A: CV risk factors: [checklist name="HTN" value="HTN|HLD|obesity"] Neuro: CN 2-12 intact, AOx3; HEENT: deferred; RESP: BBS clear and equal, respirations even & unlabored; CV: RRR, PMI @ 5th ICS, no M/R/G, no peripheral edema; ABD: SNTND, + BS x4, no hepatosplenomegaly; GU: deferred; MS: FROM intact, steady gait; SKIN: color appropriate for ethnicity, warm, dry, no rashes/wounds [text area name="variable_1" default=""]PSYCH: appropriate mood and affect A: CV risk factors: [text area name="variable_1" default=""], [select name="variable_1" value="Risk Index Class II, Major Cardiac Complication Risk 0.9%|Risk Index Class III, Major Cardiac Complication Risk 6.6%|Risk Index Class IV, Major Cardiac Complication Risk >11.0%"] Functional Capacity [select name="variable_1" value="excellent >10 METS|good 7 METs-10 METS|moderate 4 METs-6 METS|poor<4 METS"] ECHO and STRESS ordered; Educated on healthy plate guidelines, get >30 min of activity daily for optimal recovery, f/ up 2 years for reevaluation.
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