SOAP Note

This SOAP Note is prepared by Thomas S. Hadnot, a Family Practice specialist associated with Pinnacle Point Developments. The purpose of the note is to thoroughly document the health status, treatment plans, and progress of Amelia Harris. SOAP stands for Subjective, Objective, Assessment, and Plan, and it follows a specific format to ensure clear and concise medical documentation.

Subjective

• Amelia, 36 years old, presents with fatigue, diffuse weakness, and occasional headaches.

• Ms. Harris describes feelings of generalized tiredness affecting her daily activities.

• Non-smoker, moderate alcohol intake.

Objective

• Vital Signs: B.P 130/85 mmHg; Pulse 80; Temp 37.2C; Resps 16/min; Weight 130 lbs; Height 5'6".

• Physical Examination: No swollen lymph nodes; No anaemic conjunctiva; Mild paleness of skin; No visible jaundice.

• Laboratory work was ordered for blood glucose level, lipid profile, liver function tests, and full blood count.

Assessment

Patient presents with generalized fatigue, diffuse weakness and occasional headaches which requires further assessment and investigations to determine potential causes.

Plan

• Advise rest and adequate hydration.

• Limit alcohol intake.

• Patient to return for follow up visit in one week or sooner if symptoms worsen.

• Laboratory results will be reviewed and discussed at her next appointment.

Date of Note: November 12, 2050

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