Question

The SOAP note (an acronym for subjective, objective, assessment, and plan) is a method of documentation employed by health care providers to write out notes in a patient's chart,

9:31 < Back SOAP Assignment #2.docx SOAP Assignment Case Stody: Cystic Fbresis ADMITTING HISTORY The patient had first been seen at the medical center at the age of 22 months, with a history of cougA fever. nose for 7 drys. His past history had revealed the peodaction of bulky, foul-smelling stools since infancy His first upper respiratory tract infection had developed at ape4 months, and he had had a chronic cough and imtemincnt wheezing ever since. He had had acute tonsillits beonchitis, and otitis media on three separate occasioes always treated with antibiotics. The peesent iliness had been diagnosed as "asthmatic bronchitis, and the pati had been Because the so-called Teonchnis had not improved the parents had been advised to bring the child to the hospital Family history revcaled that the parents wre healthy but that the only other sibling had cystic eosis antibiotics and expecrs PHYSICAL EXAMINATION Physical examination revealed an active child in no acu distress but with an almost consant, wet-sounding cough emperature was 102 3" F. The abdomen was protuberant. The child was in the fortieth peroenile fo bright and weight. The tonsils were boggy and odemato Coarse crackles and thonchi could be auscultated over all lung fields. A moderate amount of yellow and opaque sputum was produced with cach couphing episode. The lobe and probable peeumonitis in the same area 17g%, a white blood cell (WBC)count of 21,000-and an Spo, of90% on room, air. The patomr's sweat chloride concentration was 83 mEqL(a·d0mEqL). Adupus of cystic therapist was asked to SOAP the patient. ibrosis was made. At this time, the respiratony Based en these clisical data, how would you SOAP patient? SOAPI Or

Answer 1

SOAP analysis of this patient is as follows :-

S for subjective data ( chief complaints ) - patient had fever, cough ,runny nose for 7 days .

O for objective data ( vital signs/ physical examination ) - on examination child was active with no distress, wet sounding cough, rectal temperature of 102.3°F, SPO2 - 90% ,abdomen was proturbent . Tonsils were boggy and edematous . On auscultation coarse crackles and rhonchi were present . Sputum was yellow and opaque . X-ray revealed atelectasis of right middle lobe . Suspected pneumonia .

Laboratory investigation results :-

- Hemoglobin concentration of 17%

- WBC - 21000

-sweat chloride concentration of 83 mEq/L .

A ( Assessment ) - on assessment patient was active with no distress , had fever of 102.3 degree fahrenheit and had yellow sputum on coughing.

P (plan ) - X-ray Chest ,laboratory investigation including CBC ,and chloride concentration.