Question

Write SOAP Notes for each of the following scenarios based on the example discussed in lecture. Remember, be concise and use acronyms and abbreviations wherever possible! However, do not use abbreviations or acronyms if they are on the "do not use" list. If you need a symbol you cannot easily create, describe it instead. For example, “s with a line over the top” (without) or “o with a + underneath” (female).

1. Ms. Ophelia Payne (born 6/19/1942) reported to the clinic for her weekly blood pressure check. She has not experienced any health problems since her last checkup. She reminds us not to wear latex gloves during the examination as she is allergic to latex, but she is not aware of any drug allergies. Her blood pressure is 142/80, and she takes 50 mg Atenolol daily. Her blood pressure appears to be controlled by the Atenolol. I recommended that she continue to take Atenolol as directed and return to the clinic in one week to make sure her blood pressure is still under control.

2. I.B. Burnen, a WSU student (born 4/1/1990), came to the clinic today. He stated he has extreme burning with urination and some discharge. States “I have to pee almost every 30 minutes.” He thinks he may have contracted gonorrhea. I performed a gram stain on the discharge from his penis, which was negative for gonorrhea, but showed large numbers of white blood cells. Unfortunately, he tested positive for Chlamydia. The burning with urination is likely due to the Chlamydia infection in his urinary tract. Because he is not allergic to any medications, I prescribed 100 mg Doxycycline twice a day for 10 days. Also instructed him to increase his fluid intake, but to avoid alcoholic beverages. I instructed the patient on safe sex practices.

3. Mr. M.T. Bowels, born 3/28/1963, is here today complaining of pain in his left hip that has lasted for three months. The pain becomes worse when he walks or does any exercise. His weight is 195 lbs, and he is 5’5” tall. Range of motion is normal in both hips, and he has no swelling or redness. I suspect Mr. Bowels has osteoarthritis, and we should rule out rheumatoid arthritis. Ordering a complete blood count, and an x-ray of both hips from back to front, and lateral. Instructed patient to take 600 mg ibuprofen three times a day by mouth and return for reevaluation in 2 months. He indicates that he is not allergic to any medications.

Answer 1

- SOAP Noles on 6. Subjective Data - Ms. Ophelia Payne (born 6/19/1942) re to the clinic for her weekly Bop checkun She said that she hasn't experienced . any health problem since her last check up Has known allergy of later gloves & ? no known dung allergies at Objective data Wital signs. Bien l'a2. Iso mom ttg [toolsomrity] (421 Som B .PT Vital signs - Assessment Decrease in Ho s B-bloeters .B.P for further Assessment of therapy - Slim - stenolol - song PLAN - To continue antenolol Le treatment period Pollow up & Review after week. ② Subjective Bata I. B- Burner (born wil1996) attended to clinic with coc of extreem burning with urination 8 some discharge & states that he has - to pee for every 30 minutes. ver as the thinks he has contracted gonorrhere

.. conducted for gonor here Objective data Diagroślic -lest were conducted a which was found to be negalive » It was found to be positive for Chalan . Based on subjective 8 objective date the final diagnosis was found to be L STD's inne, Chalmydia infection Assessment of therapy Doxycylin – 100 mg BD for co days to eradicat e organison PEAN NA lend intake Inlease fluid intake Avoid consumption To use Condom of alcohol beverages while having sex a → . condom D B. Subjective Data , Mr.M.T., Bowels (born 3/28/1963) attended to clinic with ac of pain in his left hip since 3m and states that pain becomes worsen when he walks or does any u No known allergies to any medications or does any to any and al

Objective CBC. x to front Data X-ray of both the hips from back are done Assessmat Based on the final subjective and Obfeéline dala diagnosis was found to be osteoarthrils PLAN Ibuprofen - Goong Tid for reevaluation. Review aften amonity follow up