Soap Note about Gallbladder stones

Soap note about gallbladder, included a real case, an example how to do the Soap note, please use always APA style, more than 3 references minimum 5 years ago.

this patient uses 3 types of medications: (be creative and search in google dosage, administration PO, frequency, example: Metformin 500 mg once a day with meals for Diabetes mellitus type 2.

Cardiology – Other Antihypertensives

Endocrinology – Oral glucose lowering agents

Miscellaneous – Not covered elsewhere

This patient has a schedule for surgery of gallbladder, but had a history of gallbladder problems, in the history you can search signs and symptoms of gallbladder stones such as:

Pain areas: in the back or upper-right abdomen

Pain types: can be severe

Gastrointestinal: indigestion, nausea, or vomiting

Abdominal: cramping from gallstones or discomfort

20190528020958soap_note_example

Solution Preview

Name: Garcia Chaviano, Maikel A	Date: 5/17/2019	Time: 1430
Age: 89	Race: Hispanic	Sex: F
Setting type: Undeserved area/population	Referral: other	Reason for visit: Scheduled Procedure
Insurance: Medicare and HMO	PMHX: unremarkable. All vaccines are current.	Time w/ patient: 25 minutes
SUBJECTIVE
CC: “I have surgery of my gallbladder. “
HPI: Two months ago, the patient walked into the facility complaining of pain in her upper right abdomen that would not go away. She also complained that she often felt pain below her breastbone and in her right shoulder. She indicated that she had tried to get the pain addressed using over the counter pain medications, but the pain continued, particularly in her upper right abdomen.

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