Case Study Information pertaining to Soap Notes

 Case Study Info for Soap Notes Composition

Relate Level Material

Case Study Details for SOAP Notes

See the following 3 patient appointments.

Rewrite the knowledge using right medical terminology.

The visits below are drafted in layman's terms and don't use the correct medical terminology. Re-write the info in medical terms pertaining to the chart. You must determine where the information is to be put in the SOAP note.

Affected person One – Chapter Six

22-year-old Black female

140/60 BP

99 F

Heart beat is 35

Breathing is 22 each minute

Patient says she is not really on any medicine at the moment

Patient declares her cause of the go to is she has severe back pain treatments for a few days now

Past has become told this lady has sickle cell anemia

Medical doctor tells sufferer they are going to draw blood and give her IV with fluids.

Physician states the IV will contain anything for the pain

Blood work showed white blood cells 4300, hemoglobin 13. 1 g/dL, hematocrit 39. 9%, platelets 162, 1000, segs sixty-five. 9, lymphs 27, monos 3. four

Physician observes patient is definitely alert

Medical doctor finds that head, ear, eyes, nose area, and throat are okay

Physician determines the patient has a sickle cell problems

Physician determines to have affected person stay by hospital right away

Patient claims she has not been ingesting much

Sufferer states " I have been capable to keep foods down and possess had not any problems visiting the bathroom”

Sufferer states this wounderful woman has been having regular head aches

Physician detects that the affected person has pain in stomach over the reduced spine

Medical professional observes which the skin color is good

Medical doctor will go back in morning hours to see individual again

Individual Two – Chapter Eight

• 26-year-old male

• Born about February a couple of, 1984

• 115/80 BP

• 98 F

• 215 lbs

• sixty two inches

• Blood sugar 2 hundred range

• Patient provides history of diabetes

• Insulin dependent

• His heart beat was 80

• His breathing price was 12-15

• Medical professional listens to his lungs and locates nothing of concern • Doctor finds simply no issues with the abdomen

• Physician informs affected person he has sore on his bottom and they'll cut the sore and get the smooth out of it. Moreover medication will probably be given. • Patient declares he is having pain in bottom location. States this individual saw acne on his bottom and then it started to harm. He declares he found ER and they opened the pimple and drained the fluids away. He declares they happened to run some research laboratory work on the fluid through the pimple yet has but to hear whatever. Patient has no other grievances. • Physician checks the head, eyes, the ears, nose and throat and no problems • Physician checks underneath her neck and locates no inflammation • Medical professional finds zero swelling in the hands or perhaps feet

• Medical doctor looks at patient's bottom and sees the drained zit. There is even now some smooth and blood vessels coming from it. • Doctor talks to individual about how to care for his sore when he should go home

Patient Three – Chapter 18

45-year-old female

Physician detects bottoms from the feet are hard and dry

The lady comes in proclaiming that she gets history of diabetes but just received insurance after lacking any for three years

125/86 BP

185 lbs

68 inches

Blood vessels was analyzed for glucose and it had been 152

Physician tells the person she is not really controlling her diabetes

Physician tells the sufferer she has state related to tingling of her hands and feet due to her diabetes

Patient's heartbeat was 104

Breathing charge was 18

Physician views the stomach is normal without pain after exam

Doctor gives the patient a pharmaceutical drug for medication for her diabetes

Patient claims she was on medicine but is actually not for three years due to the lack of insurance

Affected person reports the girl does not smoke or...

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