Medical Literacy case study

Read the following case then write a medical report using SOAP method

Lucy is a 34-year-old mother who was referred to the Medical Centre by her
general practice with a 4-week complaint of headache. She told you the
symptoms were so bad, and she sometimes fell dizziness, and you notice she is
look tired and anxious. You take her vital signs (VS), her blood pressure (BP) is
170/110 mmHg, her radial pulse (HR) is 85, his respirations (R) are 20, and her
temperature (T) is 37c. You noted that the blood pressure rate is irregular.

You tell her the doctor will be right in to see her. Doctor observed patient then
ordered CT scan and prescribed 50 mg of Atenolol PO daily for headache. The
CT scan indicated the presence of a tumor in the right frontal lobe. The doctor
ordered cranial biopsy waiting the results. Pt asked to F/U at clinic in 3-4 days
after the biopsy results come back for further treatment.
Answer
Subjective S:

- 34-year-old mother
- 4-week complaint of headache
- Pt states the symptoms were so bad and she sometimes fell dizziness

Objective O:

- Observed Pt tired and anxious

- VS= BP: 170/110 mmHg (BP irregular), HR: 85, R: 20, T: 37c.

Assessment A:

- Observed patient and ordered CT scan

- Ordered cranial biopsy
- CT scan indicated the presence of a tumor

Plan P:

- Prescribed 50 mg of Atenolol PO daily for headache

- Waiting the results of cranial biopsy
- F/U at clinic in 3-4 days after the biopsy results come back for further
treatment