goop Note ------------------------------------------------- Associate Level Material pocket Note Create collar SOAP notes using recompense medical terminology from the diligent information in vermiform process C. ?Organize the information correctly ? put the SOAP notes ? revise language where necessary Post your paper as a Microsoft® Word attachment. affected role One Chapter 6 Soap Notes escort:| 07/04/2012| Chart #:| 001| Age:| 22| Name:| Doe, Jane| date stamp of hand over:| 01/14/1990| Sex:| F| S:| | | | | | | | | | | patient role states she has had monstrous lower derriere anger constantly for 5 days. patient has not been eating much. in that location has been no vomiting with want to what the patient has been able to eat. Patient also experiencing headaches. Bowel sounds ar good and no issues utter with evacuation of same. Not currently on any medications. Has reliable a diagnosis of sickle kiosk genus Anemia in the past. | CC:| | | | | | | | | | | Acute back pain and frequent headaches| storey of Present Illness: historical Medical History:| | | | | | | | | | | stern discomfort and headaches.Sickle cell anemia| O:| | | | | | | | | | | Physical run of patients body uneventful. Patient is qui vive and responsive. Skin colour is normal and regular. indomitable pain is puzzle in abdomen above lumbar spinal cord. livestock work and labs drawn. Iv with fluids golf clubed. tide rip work results show blanched blood cells 4300, haemoglobin 13.1g/dl, packed cell volume 39.9%, platelets 162,00, Segs 65.9, lymphs 27, monos 3.4.| Vital Signs:| BP:| | PR:| | RR:| | T:| °F| W:| lbs| | | cxl/60| | 22| | 38| | 99 degrees F| | n/a| | | A:| | | | | | | | | | | Patient experiencing a sickle cell crisis| Dx:| | | | | | | | | | | Sickle cell crisis| P:| | | | | | | | | | | Patient is to be admitted to hospital. IV fluids to be administered along with pain medication via the IV. Physcian will.. .If you want to vanquish a full essay, orde! r it on our website: OrderCustomPaper.com
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