Project: A SOAP Note Case Study
Project: A SOAP Note Case Study
On this task, you’ll analyze a SOAP observe case examine that
describes irregular findings in sufferers seen in a scientific setting.
You’ll think about what historical past ought to be collected from the
sufferers, in addition to which bodily exams and diagnostic checks
ought to be performed. Additionally, you will formulate a differential
analysis with a number of doable situations.
Belly Assessment
SUBJECTIVE:
· CC: “My abdomen hurts, I’ve diarrhea and nothing appears to
Help.”
· HPI: JR, 47 yo WM, complains of getting generalized stomach
ache that began three days in the past. He has not taken any drugs
as a result of he didn’t know what to take. He states the ache is a 5/10
as we speak however has been as a lot as 9/10 when it first began. He has
been in a position to eat, with some nausea afterwards.
· PMH: HTN, Diabetes, hx of GI bleed four years in the past
· Drugs: Lisinopril 10mg, Amlodipine 5 mg, Metformin
1000mg, Lantus 10 items qhs
· Allergy symptoms: NKDA