Question

Patient: Olivia Prescott (Female)

Age: 29

Patient Statement: I've been really tired a lot lately, and losing my breathe doing simple task like brushing my teeth, and walking across the room. I noticed my heart beating really fast even when I'm sitting. This morning looking in the mirror, I feel like I am more pale than usual, then I started having my , now normal, daily pounding headache. Sometimes, if I move to quick I feel light headed, and dizzy. I thought maybe this was all symptoms from the new birth control I am on, but I haven't found anything related to it. The only thing I could think of is me having a heavy (more than normal) bleeding for almost three weeks now. I was going through almost 9 overnight pads a day. My OBGYN said the new pills have less hormones, which is why I'm bleeding more, but never said anything about the being tired all day. I was so worried that I even went to get tested for COVID-19, which came back negative. I haven't had any change in appetite, and I'm a pretty healthy eater, I don't drink, I don't smoke."

Vitals:

weight: 120 lbs, height-63 in, BP- 96/65(This is low for her), PulseRate:98 bpm(this is high for her), Respiratory Rate: 18 bpm(This is high for her)

CBC:

Low hemoglobin (Hg) and hematocrit (Hct)

Low mean cellular volume (MCV)

Low ferritin

Low serum iron (FE)

High transferrin or total iron-binding capacity (TIBC)

Low iron saturation

Instructions:

Use the information provided to create a SOAP note. Be sure to use only the proper medical term and not the "layman's term." Be sure to include the Vitals in the objective, along with the CBC. You are to come up with at least 3 differential diagnoses in the Assessment portion of your SOAP. and be sure to map out suggested treatment for the condition/diagnosis you believe the patient has. Your SOAP note should be approx. 1-2 pages. I will take off points for not using proper terms, or misspelling. You will have until Wednesday evening to complete.

Answer 1

SOAP notes are a way to organize information about patients

S - Subjective

O - Objective

A - Assessment

P - Plan

Subjective Component

This is a very brief statement of patient as to purpose of office visit or hospitalization.

It includes

• Patient, significant other, family or staff tells the professional
• can include symptoms, feelings, history and progress
• may be in format of patient reports or given as direct quote
• These statements are chosen to illustrate a point made in the assessment.

Objective Component

It includes the formation that the physician observes, elicits and measures from patients current presentation

Objective components includes :

• Vital signs and measurements such as weight and height
• Findings from physical examinations, including basic systems of cardiac and respiratory, affected systems, possible involvement of other systems, pertinent normal findings and abnormalities
• Results from laboratory and other diagnostic tests already completed.

Assessment

It is a cogent & concise summary of patients main diagnosis, including a differential diagnosis.

• Assessment will also include possible and likely etiologies of patient's problem.
• Assessment also records a patient's progress since last visit, and overall progress towards patient's goal from physician's perspective.

Plan

Plan is what physician will do to treat patients concerns such as ordering further labs, radiological work up, ECG, referrals given, procedures performed, medications given and education/ counselling provided.

Plan should also include goals of therapy and patient- specific drug and disease - state monitoring parameters.

The plan includes various Components

• Diagnostic component
• Therapeutic component
• Referrals
• Patient education component
• Disposition component

SOAP	PATIENT DETAILS
Subjective Components	Patients Name : Olivia Prescott Age: 29 years C/o breathing difficulty and tiredness, palpitation. headaches and pallor. Menorrhagia for three weeks. She is on Birth control pills. Good appetite and following healthy diet No habits of smoking and alcoholism.
Objective Components	Anthropometric measurement Height - 63 inches Weight - 120lbs Vital signs Temperature - afebrile BP - 96/65 mm of Hg (Hypotension) Pulse rate - 98 bpm ( Tachycardia) Respiratory rate - 18 breaths per minute ( Tachypnea) Complete blood count - Anemia
Assessment	Anemia Menorrhagia Side effects of less hormone birth control pills
Plan	Proper assessment of the patients side effects of the birth control pills Health education regarding diet containing iron supplements, citrus fruits, leafy vegetables. Maintaining activities that causes tachycardia, tachypnea and orthostatic hypotension. Adjusting the dose of the birth control pills with the OBGYN. Proper assessment of the amount of bleeding, the color, odor etc. Regular follow up for the prognosis Discharge monitoring with the near by clinic, community health center or home nurse.