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    S.O.A.P Notes Activity 1

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    YESID MAURICIO GOMEZ CAMPOS
    Soap medical method excercise

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    © All Rights Reserved
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    S.O.A.P Notes Activity 1

    Uploaded by

    YESID MAURICIO GOMEZ CAMPOS
    8 views2 pages
    Soap medical method excercise

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    © © All Rights Reserved

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    DOCX, PDF, TXT or read online from Scribd

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    Soap medical method excercise

    Copyright:

    © All Rights Reserved
    Download as DOCX, PDF, TXT or read online from Scribd
    Download as docx, pdf, or txt
    8 views2 pages

    S.O.A.P Notes Activity 1

    Uploaded by

    YESID MAURICIO GOMEZ CAMPOS
    Soap medical method excercise

    Copyright:

    © All Rights Reserved
    Download as DOCX, PDF, TXT or read online from Scribd
    Download as docx, pdf, or txt
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    S.O.A.

    P Notes Activity
    Medical Records Activity
    1. Alex Miller 32 yr old male suffering from back pain and headaches following
    a car accident. Alex describes being rear-ended at a stoplight by another
    vehicle. Reports headaches that have persisted since the collision. No loss of
    consciousness or other injuries reported. While at the hospital they performed
    a physical examination of Alex. The exam showed tenderness and stiffness in
    the cervical spine. Limited range of motion in the neck, especially on lateral
    movement. No neurological deficits observed. The doctor concluded that Mr.
    Miller had suffered a whiplash injury with associated neck pain and
    headaches. The doctor prescribed muscle relaxants for pain management.
    Recommended rest and avoid strenuous activities. Follow-up with PCP if
    symptoms persist.
    Subjective
    Objective
    Assessment
    Plan
    2. Sarah Thompson 28 Female Sarah reports a constant headache for the past
    two days. Describes the pain as a pressure sensation on both sides of her
    head. No specific triggers identified. Denies visual disturbances, nausea, or
    sensitivity to light. Reports occasional stress at work. The doctor examined
    Sarah and found the clients Blood Pressure: 118/72 mmHg, Heart Rate: 82
    bpm Respiratory Rate: 18 breaths per minute and her temperature was
    98.6°F. Physical Examination of Sarah showed a Normal neurological
    examination there were No signs of meningeal irritation. Sarah was
    diagnosed Tension-type headache, likely related to stress and work-related
    factors. Dr. Smith prescribed over-the-counter analgesics for pain relief.
    Schedule a follow-up in two weeks to assess response to treatment.

    Subjective
    Objective
    Assessment
    Plan
    3. Jessica reports slipping on a wet floor at her school cafeteria and falling onto
    her right side. She describes immediate pain and swelling in her right ankle.
    Reports difficulty bearing weight on the affected ankle. Physical Examination
    of Jessica had swelling and tenderness. She had limited range of motion in
    the ankle joint. Ecchymosis (bruising) noted on the lateral side of the ankle.
    No other visible injuries observed. Her right ankle sprain because of a slip and
    fall. Prescribe pain medication and anti-inflammatory drugs. Apply ice to the
    injured area and recommend rest. Advise the use of crutches to avoid weight-
    bearing on the affected ankle. Schedule a follow-up appointment in one week
    for reassessment.

    Subjective
    Objective
    Assessment
    Plan

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