Document Soap Note Explained for Students (Easy Guide)

This question tests key academic concepts commonly covered in coursework.

What This Question Is About

This question relates to document soap note and requires a structured academic response.

How to Approach This Question

Start by identifying the main issue, then apply relevant academic frameworks.

Key Explanation

This topic involves document soap note. A strong answer should include explanation, application, and examples.

Original Question

Document a SOAP note on a 72 year-old male who has a longstanding history of hypertension and diabetes and presents with a complaint of pruritis, lethargy, lower extremity edema, nausea and emesis. He denies any other medical illnesses. Laboratory Data Chemistry Normal Values Urinalysis Sodium 133 136-146 mmol/L pH 6.0 Specific gravity 1.010 Protein 1+ Glucose negative Acetone negative Occult blood negative Bile negative Waxy casts Potassium 6.2 3.5-5.3 mmol/L Chloride 100 98-108 mmol/L Total CO2 15 23-27 mmol/L BUN 170 7-22 mg/dl Creatinine 16.0 0.7-1.5 mg/dl Glucose 108 70-110 mg/dl Calcium 7.2 8.9-10.3 mg/dl Phosphorus 10.5 2.6-6.4 mg/dl Alkaline Phosphatase 306 30-110 IU/L Parathyroid Hormone 895 10-65 pg/ml Hemoglobin 8.6 14-17 gm/dl Hematocrit 27.4 40-54 % Mean cell volume 88 85-95 FL 24-hour urine protein and creatinine – volume 850 ml, protein 600 mg/dl and creatinine 180 mg/dl Renal ultrasound- Right kidney 9 x 6.0 cm, Left kidney 9.2 x 5.8 cm Both kidneys illustrate hyperechogenicity and no hydronephrosis.

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