Case Study Information for Soap Notes

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Associate Level Material
Case Study Information for SOAP Notes

Read the following three patient visits.

Rewrite the information using correct medical terminology.

The visits below are written in layman’s terms and do not use the correct medical terminology. Re-write the information in medical terms for the charts. You must determine where the information is to be placed in the SOAP note.

Patient One – Chapter Six

22-year-old African American female

140/60 BP

99 F

Pulse is 38

Breathing is 22 per minute

Patient states she is not on any medicine at the time

Patient states her reason for the visit is she is having severe back pain for 5 days now

Past has been told she has sickle cell anemia

Physician tells patient they are going to draw blood and give her IV with fluids.

Physician states the IV will contain something for the pain

Blood work showed white blood cells 4300, hemoglobin 13.1 g/dL, hematocrit 39.9%, platelets 162,000, segs 65.9, lymphs 27, monos 3.4

Physician observes patient is alert

Physician finds that head, ears, eyes, nose, and throat are okay

Physician determines the patient is having a sickle cell crisis

Physician determines to have patient stay at hospital overnight

Patient states she has not been eating much

Patient states “I have been able to keep foods down and have had no problems going to the bathroom”

Patient states she has been having regular headaches

Physician finds that the patient has pain in abdomen over the lower spine

Physician observes that the skin coloring is good

Physician will return in morning to see patient again

Patient Two – Chapter Seven

• 26-year-old male
• Born on February 2, 1984
• 115/80 BP
• 98 F
• 215 lbs
• 62 inches
• Blood sugar 200 range
• Patient has history of diabetes
• Insulin dependent
• His pulse was 90
• His breathing rate was 15
• Physician listens to his lungs and finds nothing of concern • Physician finds no issues with the abdomen
• Physician informs patient he has sore on his bottom and they will cut the sore and get the fluid out of it. In addition medication will be given. • Patient states he is having pain in bottom area. States he saw pimple on his butt and then it started to hurt. He states he came to ER and they opened the pimple and drained the fluids out. He states they ran some lab work on the fluid from the pimple but has yet to hear anything. Patient has no other complaints. • Physician checks the head, eyes, ears, nose and throat and there are no problems • Physician checks under her neck and finds no swelling • Physician finds no swelling in the hands or feet

• Physician looks at patient’s bottom and sees the drained pimple. There is still some fluid and blood coming from it. • Physician talks to patient about how to care for his sore once he goes home

Patient Three – Chapter 14

45-year-old female

Physician finds bottoms of the feet are hard and dry

She comes in stating that she has history of diabetes but has just received insurance after not having any for three years

125/86 BP

185 lbs

68 inches

Blood was tested for sugar and it was 152

Physician tells the patient she is not controlling her diabetes

Physician tells the patient she has condition related to numbness of her hands and feet due to her diabetes

Patient’s pulse was 104

Breathing rate was 16

Physician sees the abdomen is normal with no pain upon exam

Physician gives the patient a prescription for medication for her diabetes

Patient states she was on medication but has not been for three years due to the lack of insurance

Patient reports she does not smoke or...
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