Question

Part C: The Use of the Medical Terminology of the Integumentary, Musculoskeletal, and Nervous Systems in Medical Reports

Select a body system. (Integumentary, Musculoskeletal, and Nervous Systems)

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

S:

O:

A:

P:

Answer 1

Integumentary system :-

S: Patient states “I didn’t even notice my legs were swollen until I tried to put my shoes on before you got here.”

O: Patient has 3+ edema with no signs of respiratory distress

A: Patient exhibiting early signs of heart failure exacerbation due to increased edema but no signs of respiratory distress. Patient not able to manage or recognize changes in lower extremity edema as a warning sign effectively.

P: Evaluate patient’s ability to verbally report signs of heart failure. Assess edema, lung sounds for signs and symptoms of heart failure.