Medical Terminology: A Case Study
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 …show more content…
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
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 …show more content…
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