Reference no: EM133911302
Patient Information:
Lela Snow is a 48 y/o female Accountant who presented to your urgent care facility today with complaints of severe sharp abdominal pain, especially after meals that started 3 days ago and is now constant.She ia allergic to Penicillin. Her Mother has history of Hypertension and type 2 diabetes and is aliveShe has Type 2 Diabetes and Hypertension and talks lisinopril 10mg daily and metformin 500mg twice a day. She doesn't smoke, drinks occasional wine on the weekends, denies using illicit drugs She is married and has 2 children by c-section. LMP August 12th She denies pain or joint swelling. She states she took Pepcid and motrin for the pain without relief. Her father has a history of Type2 diabetes and is still alive. She appears in moderate distress. Her heart rate and rhythm with normal S1,S2 noted and no ectopy. Her abdomen has tenderness in the right upper quadrant, positive Murphy's sign. She denies Dizziness, weakness or numbness. She denies and pain with urination, frequency or blood in her urine.
Her Vital Signs:
o Blood Pressure: 150/90 mmHg
o Heart Rate: 88 bpm
o Respiratory Rate: 18 breaths per minute
o Temperature: 98.6°F
o Oxygen Saturation: 98% on room air
o Height: 5'5"
o Weight: 180 lbs
o BMI: 30.0
She reports feeling fatigue, but denies any weight loss or fever. Her lung sounds are clear to auscultation bilaterally. Her skin is warm and dry to touch. She denies having any headaches, vision changes or hearing loss. She denies chest pain, palpitations or edema
o Her Lab values are as follows: CBC:
WBC: 7.5 x 10^3/µL
Hemoglobin: 13.5 g/dL
Hematocrit: 40.2%
Platelets: 250 x 10^3/µL
Chem 7:
Sodium: 140 mmol/L
Potassium: 4.2 mmol/L
Chloride: 102 mmol/L
Bicarbonate: 24 mmol/L
BUN: 15 mg/dL
Creatinine: 0.9 mg/dL
Glucose: 110 mg/dL
o Liver Panel:
AST: 45 U/L (elevated)
ALT: 50 U/L (elevated)
ALP: 120 U/L
Total Bilirubin: 1.2 mg/dL
Albumin: 4.0 g/dL
o Ultrasound: Gallstones present in the gallbladder, no signs of cholecystitis.
She denies and cough. Her neck is supple, no lymphadenopathy. Her head is normocephalic, atraumatic, PERRLA, EOMI. She denies any rash, lesions, or Shortness of breath. She denies any cough, denies diarrhea or constipation. Her extremities are non-edematous with pulses +2 Bilaterally. She denies any History of anxiety or depression. She has a past Surgical History of an appendectomy
Instructions for students:
The above is scrambled information which will make up the "S" and "O" portions of the SOAP note. Read the narrative and place the information in the appropriate category/location. Get Assignment Help from trusted tutors.
Write the SOAP note exam using the information provided. You could find a sample format to help guide your write up in your course document section of
If the above narrative does not provide information for your ROS or PE then assume these bullets or categories are normal and fill in those blanks with what is normal for those sections. DO NOT LEAVE THEM BLANK. This is to be a comprehensive SOAP note.
If you feel there are other diagnostic exams necessary for this case, then indicate them in your treatment plan with the rationale.
Continue your SOAP note with your "A" making sure to include at least (3) differentials for your case.
Lastly, include all the pertinent information in your "P" Plan including (if applicable) follow up, treatment plan, referral and teaching/ education plan. Remember to consider health promotion and disease prevention.