Medical Phenomenology: Soap Notes

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

Soap Notes Date: | 09/26/2011 | Chart: | 001 | Age: | 22 | Name: | Jane Doe | Date of Birth: | 02/11/89 | Sex: | F |

S: | Patient has sever lower back pain that was constant for 5 days, she hasn’t been eating, no vomiting after eating, also has been having headaches. Bowel signs and sounds are good. Patient isn’t on any meds currently. Has been diagnosed in the past with sickle cell anemia. | CC: | Lower
back pain for five days. | History of Present Illness: regular headachesPast Medical History: Sickle cell anemia | O: | Pt.
physical exam of body is fine. Pt has normal, regular skin color and is very alert. Discovered pain is present in lower abdomen over spine. Blood work and labs were done. Ordered IV with fluids. Blood work showed white blood cells 4300, hemoglobin 13.1 g/dL, hematocrit 39.9%, platelets 162,00, segs 65.9, lymphs 27, monos 3.4 | Vital Signs: | BP: | 140/60 | PR: | 22 | RR: | 38 | T: | .99 °F | W: | Lbs. | |
| A: | Patient is having a sickle cell crisis. | Dx: | Sickle cell crisis | P: | Pt. will be admitted to hospital, IV will be administered with fluids and pain meds, will return in the morning to see pt. again. |

Patient Two – Chapter 7

Soap Notes Date: | 09/26/2011 | Chart #: | 012 | Age: | 26 | Name: | John Doe | Date of Birth: | 02/02/1984 | Sex: | M |

S: | Pt.
states that he has been having pain on his bottom area. Previously he went to the ER and had the area opened for drainage. No other complaints. | CC: | Pain on bottom buttock area | History of Present Illness: DiabetesPast Medical History: Past history of diabetes | O: | Physical exam of pt. was normal with no problems. Abdomen is fine, checked under neck area and there’s no swelling, also no visible swelling in hands or feet. Observes the pt. bottom and sees the drained pimple which still has drainage coming from it. | Vital Signs: | BP: | 115/80 | PR: | 90 | RR: | 15 | T: | 98°F | W: | 215lbs | | | A: | Patient still has drainage coming from bottom buttock area after it was cut open at the ER previously. | Dx: | Infected site on buttock. | P: | Will make a small incision on lower area of buttock to allow proper drainage. Inform pt. of the care of the area when he goes home and prescribe pt.meds. |

Patient Three – Chapter 14

Soap Notes Date: | 09/26/11 | Chart #: | 013 | Age: | 45 | Name: | Janet Doe | Date of Birth: | 04/12/1966 | Sex: | F |

S: | Pt. states that she has a history of diabetes but hasn’t seen a physician in 3 yrs. due to lack of medical insurance. She states that she hasn’t been feeling good. She isn’t a smoker nor does she drink.
| CC: | Overall not feeling well. | History of Present Illness: Numbness of hands and feet Past Medical History: Diabetes | O: | Upon physical exam, the abdomen is normal. Pt. feet and hands appear to have numbness, also have hardness on bottom of feet and are dry, heart sounds are fine, blood sugar was tested and it was 152. Also noticed some skin discoloration in pt. | Vital Signs: | BP: | 125/86 | PR: | | RR: | | T: | °F | W: | 185 lbs | | | A: | Patient is developing more issues with her diabetes because she isn’t trying to control it and have not been taking care of herself. | Dx: | Sugar high from no maintenance of diabetes. | P: | Prescribe patient meds and instruct her to re-visit the office in one month. |