13.1. Joan Duffy iHuman

Complete a SOAP note for the patient using the SOAP note template as a guide. The SOAP note should NOT be in a table format. This assignment should be done in a single-spaced Word document.

 

I-human interview 1. 2. 3. 4. 5. What is your name? Joan Duffy Where are you? In the emergency room What time is it? I don’t know What happened? I don’t know How can I help you today? The people at my home say I am acting funny. I don’t know what they mean. Talk to the nurse here. 6. How can I help you today (nurse)? The staff at the home has noticed that she seems confused at times, having more difficulty than usual staying on task, needing numerous reminders to complete her living chores. She seemed to be eating less and drinking more water and juices, so we had her tested. The blood lab called today and said that we should take Ms. Duffy to the ER because her recent blood work had her Na 116. 7. Any other symptoms or concerns we should discuss? She’s complaining of lightheadedness, headache, and upset stomach. But you should really ask her how she feels. 8. Any other symptoms or concerns we should discuss (patient)? I have a headache. I feel a little sick to my stomach. I’m lightheaded…sometimes. 9. Do you have any pain anywhere? If so where? Yeah. In my head. 10. When did your headache start? A few days ago, or was it a few weeks ago. I guess I am not sure. Johnny, did you notice? 11. When did her headache start? I think along with the upset stomach and confusion. Please confirm with her. 12. Does anything make your headache better or worse? I don’t know. The light doesn’t bother me, if that’s what you mean!