Week 6 Soap Notes

Topics: Blood sugar, Diabetes mellitus, Sickle-cell disease Pages: 4 (692 words) Published: July 29, 2012

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:Sat, Aug 27, 2011 04:05 pmChart #:1234-567-1234Age: 22 Name:Susan SmithDate of Birth:03/11/89Sex
: F

S:Patient says she has been having acute back discomfort over the past 5 days and frequent headaches. Has been advised that she has got sickle cell anemia.
Affected person isn't on any medicine.
Affected person says she has not been eating food much.
CC:Acute back discomfort and frequent headaches.

Background of Current Condition: Back discomfort and headaches

Previous Health Background: Sickle Cell Anemia

O:Skin: Shade is typical
HEENT: Usual
Affected person is cautious.
Doctor realizes that the affected person has ache in abdomen above lumbar spinal cord Affected person is informed that she is likely to get blood and provide her IV with liquids. IV will also include medication for ache.

Vital Signs:BP:140/60PR:38RR:22 T:99°FW:150lbs
A:Blood function results:
WBC: 4300,
HGB: 13.1 g/dl
HT: 39.9%
PLTS: 162,00
SEGS: 65.9
Monos: 3.4
Frequent headaches and acute back pain because of sickle cell crisis. Dx:Sickle cell Crisis
P:Doctor admits affected person in hospital immediately.
Doctor will come back in the morning hours to see affected person once again.

Patient Two – Chapter 7

Soap Notes

Date:Mon, Aug 22,2011Chart #:123-456-789Age: 26
Name: Mike JonesDate of Birth:02/02/1984Sex: M

S:HEENT: Normal
Neck: Supple, not any swelling
Breathing: No problem
Extremities: Not any swelling
Stomach : Not any problem
Blood sugar :200mg/dl
Affected person says he noticed abscess on his buttock and is having ache. He had been observed in the ER and a cut was made....
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