Question

The Use of Medical Terminology of the Endocrine, Cardiovascular, and Respiratory Systems in Medical Reports

Select a body system (Endocrine System, Cardiovascular System or the Respiratory System).

Create an example of a brief detailed medical note written in SOAP format for your selected body system.

S:

O:

A:

P:

Answer 1

Example of the SOAP format for the Endocrine system

Type 1 Diabetes mellitus:

Subjective Data:

Chief complaint: 45 years male patient with a complaint of uncontrolled blood sugar level.

History o present illnesses: Patient with a history of fatigue, frequent urination, and tingling of the feet.

Medical history: Had hypertension for 5 years.

Social history: Had a history of smoking for the past 15 years.

Medication: On regular Lantus insulin 60units in the morning and 40 units in the evening.

Objective Data:

Vitals: BP 140/90 mmHg, HR: 86bpm, Temp: 98.2 F

Lab reports: HbA1c - 9.4, Urine microalbumin - 92,

Alkaline phosphate elevated.

Assessment:

Fasting blood glucose level checked using glucometer shows increased blood glucose levels.

Increased chance of diabetic neuropathy as a result of microalbuminuria.

Improper diet intake causes uncontrolled blood sugar.

Intake of herbal medicine for the control of diabetes.

Plan:

Humalog added prior to insulin at night.

Check blood sugar for every 6 hours.

An appetizer is given for proper food intake.

Avoid the use of herbal products.

Encourage physical activities.

Health educates about the management of blood sugar and diet intake.