Question

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

Select a body system (Gastrointestinal System or the Urinary 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

Medical reports a vital source of information to know about patients health history that includes demographic profile, socioeconomic status, past illness, family history, present medical history, surgical history, drug history , list of medications currently taken by patient, laboratory studies.

All qualified health professionals must write medical reports in an organized way, legibly, clear and concise. Using structured and comprehensive format like SOAP makes medical report more tidy.

SOAP format includes the components like

SUBJECTIVE data : data information given by patient in his own words.

OBJECTIVE data : data collected by health worker on observation.

ASSESSMENT : assessment is done using a structured tool or using laboratory diagnosis to rule out the underlying problems.

PLAN : last step Involves plan of action to alleviate suffering of patient or palliative or surgical treatment.

SOAP format medical report for gastrointestinal system

Subjective data : Patient states " I have severe abdomen pain it's like cramping and in addition projectile vomiting and loose stools"

Objective data: on observation patient vitals T - 100.6 deg F,

RR - 22/ breaths / Mt , Pulse rate : 60 beat / Mt, BP - 90/80 mm Hg.

Assessment : on assessment patient have loose stools containing mucus and bloody. Hyperthermia as evidenced by fever. Vomiting persists immediately after food intake. Patient eyes are sunken , tongue coated with weak thready pulse. Patient is dehydrated due to more frequent loose stools and vomiting.

Plan :

Initial management focused on treating dehydration as untreated may leads to Hypovolemic shock.

To administer Fluid replacement with isotonic sodium chloride.

To send stool culture to detect causative organism and the sensitive antibiotics.

Administer antiemetics to stop vomiting.

Encourage patient to drink more fluids.

Avoid dietary dairy products in case of lactose intolerance.

Maintain personal hygiene to prevent spread of infectious diarrhea.