Autumn Neumann

November 27, 2020

Professor Daniel Baird
Writing Project

SOAP Note in the Medical Field

Medical Case-

Here is an example of a case being documented for a patient. A client walks into the
clinic shaking and complains that they don’t feel well. Upon checking in, they state to the
receptionist they have had pain on their side for several hours. They checked in and when being
assessed they are found to have lower right quadrant pain and a fever. The medical examiners
also see that they are squirming and seem restless. They proceeded with their evaluation
gathering as much facts as they can from the patient. They then create a care plan and evaluate
the patient for treatment.

Subjective-
• Patient states that they have “pain in stomach”. Patient states they have been throwing up
all night long until this morning and that the pain has become worse over time. Patient
states that the pain radiates from the right side to their belly button. Patient states that the
pain began around 9:00pm last night in the evening. Patient states that the pain goes from
sharp when moving and is a constant burning pain. Patient states that movement makes
the pain worse. Patient did not report having any history of pain in stomach or issues that
could be associated with the pain and symptoms today. Patient did state that they took
Tylenol to help with fever and pain, but pain and fever still remain.

Objective-
• The patient presents pain by being hunched over, squirming and restlessness. The right
side when palpated is ridged. Patient also winces when area is touched. Fever measured
at 101.5 with a blood pressure reading of 150/90. Patients other vitals are stable with an
O2 reading of 95% and pulse 80.

Assessment/Problem List-
• Patient is presenting with signs and symptoms that would seem to indicate appendicitis.
Plan-
• Plan is to order an ultrasound and blood work to confirm diagnosis. Patient will then be
treated with possible surgery and antibiotics. Patient will be instructed to do a follow up
after surgery and check for any signs of infection. Patient will be instructed after surgery
to rest and take time off work to heal from the surgery. Patient will also be subscribed
patient medication for comfort during the healing process.