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
Ambulating rapidly

O: Vitals:
Pulse 110
BP 120/80
Temp 37
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
Lungs: Clear
Abdomen: hyperactive bowel sounds

Glucose 60

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. 
Condition improving. 
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.
Breathing is also advised
Will reassess


  1. Hang in there Elizabeth! I love this post, though. It reminded me of a question I was writing in my head after I finished Step 2. It goes like this:

    A 27 year old female medical student presents with psychomotor agitation and mood lability. She is unable to sleep due to anxiety. She is fearful about her future and reports impulsive urges of self-harm. She is inconsolable and unresponsive to reason. Passive suicidal ideation is present.

    What is the most important next step in management?

    A) Prescribe Celexa
    B) Set up outpatient counseling
    C) Admit to psychiatric inpatient
    D) Advise her to reduce stress
    E) Electroconvulsive therapy

    Needless to say, I've recovered from this time. (Don't worry! :)
    Hope you and Andy are doing well!

  2. Food for the soul is as beneficial as food for the stomach. Good to hear some thoughts about life. Hang in there. You will be a skilled and compassionate doctor.

    Love ya tiger,

  3. and you still only make $16.67 per hour X 60 hours per week! Love ya tiger, Mom

  4. Happy Birthday.

    Love ya tiger, Mom

  5. Given the bankrupt state of the country and healthcare "reform" which seems to equate many physician fields with nursing, despite evidence and common sense (the fact that patient care will suffer dramatically), do you think that there will be a difference between being an ob/gyn and midwife in the future ?

    or will logic and common sense not matter because we are bankrupt as a country ?