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Axia Material

SOAP Note
Create three SOAP notes using correct medical terminology from the patient information in Appendix C.

Organize the information correctly Format the SOAP notes Revise language where necessary

Post your paper as a Microsoft Word attachment. Patient One Chapter 6

Date: Name:

9/18/2011 Sally Pain

Soap Notes Chart 1234-6


#: Date of Birth:

Age: 22 Sex: F

12/06/1989

S:

The patient is a 22 year old African American female complaining of severe back pain for 5 days, and regular headaches. Currently on no medications. No [changes in the bowel or bladder habits. Able to keep food down, no nausea or vomiting.

CC:

Having general decrease in appetite Cell Anemia

History of Present Illness: Past Medical History: Sickle

O:

Vital signs B/P : 140/60 ; P: 70 BPM ; R : 22 breaths ; T: 99.0 Patient is alert. Pupils round reactive to light. No lymphatonopathy, no thyromegaly, bruits and neck supple. Abdominal exam revealed pain on palpitation over the lower spine. Skin warm and dry to touch. Color pink.

Vital Signs:

BP:

PR:

RR:

T: F

140/60

70

22

99.0

W: Lb:125

HCA/220r7

A:

Blood work up realed white blood cells 4300, hemoglobin 13.1g/ dl , hematocrit 39.9%, platllets 162,000, segs 65.9, lumphs 27, and monos 3.4

Dx:

Sickle Cell Crisis

P:

Admit patient to hospital overnight. Start IV fluids and give pain medication. Will do follow up visit in the morning.

Patient Two Chapter 7

Date: Name:

9/18/1911 Chris Pimple

Soap Notes Chart 1234-7


#: Date of Birth: 12/07/1985

Age: 26 Sex: M

S:

The patient is a 26 year old male in ER today wit complaint of painful pimple on buttocks. Patient without any other complaints.

CC: History of Present Illness: Past Medical History: Significant

for insulin dependent diabetic

O:

Vital signs as noted below. Pupils round active to light. Blood sugar range 200. .Lungs is clear to auscultation. Resonant to percussion. No scleroicteris, moist mucus membranes. No lymphanopathy, no thyromegaly bruits, neck supple. Abdominal normal active bowel sounds in quadrants.

Vital Signs:

BP: 115/80 PR: 90 RR: 15 T: F98.0 W: Lbs215

HCA/220r7

A:

Examination of buttock reveals draining abscess. Drainage is serousanginous. Culture and sensitivity of drainage.

Dx:

Abscess

P:

Incision and drainage of abscess. Prescribe antibiotics on discharge home. Education and instructions on care will be given.

Patient Three Chapter 8

Soap Notes
Date: 09/18/2011 Name: Betty Numbness Chart 1234-14 #: Date of 12/14/1966 Birth: Age: 45 Sex: F

S: 45 year old female, complains of not feeling well. Patient has history of diabetes but not has taken her medicine for 3 years due to lack of insurance. Patient advised she does not teat glucose levels; she goes by how she feels. Patient denies smoking or drinking.

CC: History of Present Illness: Diabetes Past Medical History:

O:

Vital signs as noted below. The heart rate, respiration, and blood pressure all in normal limits.Exam shows abdominal exam revealed normal round abdomen with no pain. No tenderness or abnormal sounds. No abnormal bowel sounds in the four quadrants. Physician finds that the patient Neuropathy in hands and feet. Physician
observes that the patient has some cyanosis. Head, eyes, ears, nose and throat are within normal limits.

HCA/220r7

Vital Signs:

BP:125/86

PR:104

RR:16

T: F W: Lbs: 185

A: Blood was tested for glucose level showing 152 mg/ d L

Dx:

Neuropathy

P: Physician tells the patient she has condition called Neuropathy. Patient is given a prescription for medication for her diabetes. Patient was advised to start using the glucose motor to test her glucose levels and record the results and bring with her to next visit. Physician wants patient to return to office in 1 month.

HCA/220r7