A uterus loving, cookie baking, resident doc with a flair for food, science and medicine
Thursday, August 5, 2010
personal SOAP note
A SOAP note, for those not in medicine, is a progress note to assess and evaluate a patient. First, one starts with the subjective, what the patient tells the provider.Objective includes things that the provider notices and provide more information about the physical state including physical exam, vital sign, imaging, and lab reports.Assessment and plan are more straight forward.This is a personal progress note…
S: Feeling well today.
Back aches, relieved by rest.
Infrequent voiding, poor PO intake
Occasional palpitations--worsened by pager, improved by alcohol.
Denies chest pain
No shortness of breath
General: alert, questionable orientation to time of day or day of week, smiling and grimacing simultaneously, pressured speech.
Denies suicidal or homicidal ideation—usually. Mood labile
Abdomen: hyperactive bowel sounds
A: 26 y/o G0 s/p day #34 OB/GYN internship initiation.
Patient making questionable progress in her treatment course resulting in exhaustion and occasional idiocy.
Tachycardia secondary to physical exertion and anxiety.
Hypoglycemia due to poor oral intake
Residency is a condition that can only be cured with time, 4 years on average.
Treatment guidelines include constant focus, increased caloric intake (perhaps a bag of peanuts in the pocket or a granola bar that can be rapidly consumed), increased fluid intake and very comfortable shoes.