Question

Mrs. Joy Smith was waiting in the lobby when she suddenly felt faint. She approached the receptionist who immediately called for the MA. Mrs. Smith tells you that she is not feeling well, is very dizzy, and feels as though she is going to faint. Her vital signs are as follows: Temperature 98.4, Respirations 22, Pulse 100, Blood Pressure 80/40. Her skin is clammy and appears very pale.
Required:
Chart this scenario as a SOAP note.

Answer 1

Answer:

Explanation:

S:Patient with complaint of dizziness and states she is not feeling well and feels as if she is going to faint.

O: Temperature 98.4, Respirations 22, Pulse 100, Blood Pressure 80/40.

A: skin is clammy and appears very pale.

P:Hypotension- change positions slowly, IV hydration, check CMP, obtain EKG, stat glucose