Shadow Health Assignments
Chelsea Warren Type 1 Diabetes Shadow health SOAP Note
SOAP NoteActivity Time: 8 min
Subjective Documentation:
Student Response: Chelse reports feeling better and ready to go home. She was diagnosed with DKA 2 days ago She was having nausea and vomiting before her father brought her to the ED. Chelsea reports that she had been feeling unwell for 10 days before the hospitalization. She reported having excessive thirst and frequent urination for about 10 days before the DKA episode Chelsea Warren Type 1 Diabetes Shadow health SOAP Note.
Model Note: CC: “Diabetes” HPI: Chelsea Warren is an 11-year-old Caucasian female hospitalized with new-onset type 1 diabetes. This is day 3 of her hospitalization. She is a good historian and able to answer questions appropriately. Her father is present in the room with her. She is due to be discharged home today. Chelsea Warren Type 1 Diabetes Shadow health SOAP Note. Chelsea was brought to the ED at 8:30pm 3 days ago by her father two days ago with dizziness, vomiting, and lethargy. She wasn’t feeling well during a horseback riding lesson and hadn’t been feeling well for the past few days. She was diagnosed with Diabetic Ketoacidosis and Diabetes Mellitus 1. She has admitted with a blood sugar above 500 mg/dL PMH: No previous hospitalizations. Nearsightedness diagnosed at age 8. Wears corrective lenses. Up to date on immunizations PSH: No previous surgeries Allergies: NKDA Medications: Started during hospitalization- 0.9% NaCl IV continuous 100ml/hr Insulin glargine – 5 units HS Insulin lispro – sliding scale AC BG 125-174 = 1 unit BG 175-224 = 2 units BG 225-274 = 3 units…Chelsea Warren Type 1 Diabetes Shadow health SOAP Note.
Title: Chelsea Warren Type 1 Diabetes Shadow Health SOAP Note
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Subjective Documentation:
Chelse mentions feeling better and wanting to go home. She received a DKA diagnosis two days ago. She experienced nausea and vomiting before her father took her to the emergency department. Chelsea shares that she had been feeling unwell for around 10 days prior to hospitalization. She also talks about having extreme thirst and frequent urination for about 10 days before the DKA incident.
Model Note:
Chief Complaint: “Diabetes”
History of Present Illness (HPI): Chelsea Warren, an 11-year-old Caucasian girl, is in the hospital due to new-onset type 1 diabetes. This is her third day in the hospital. She can provide a clear account of her condition and answer questions well. Her father is present in the room. She’s scheduled to go home today. Chelsea was taken to the emergency department by her father at 8:30 PM three days ago. She was experiencing dizziness, vomiting, and tiredness. Her symptoms worsened during a horseback riding lesson, and she hadn’t been feeling well for a few days before that. She was diagnosed with Diabetic Ketoacidosis and Type 1 Diabetes. Her blood sugar level was above 500 mg/dL at admission.
Past Medical History (PMH): No prior hospitalizations. She was diagnosed with nearsightedness at age 8 and wears glasses. She’s up-to-date on immunizations.
Past Surgical History (PSH): No past surgeries.
Allergies: No known drug allergies (NKDA).
Medications: Medications started during hospitalization include 0.9% NaCl IV continuously at a rate of 100ml/hr, Insulin glargine – 5 units at bedtime, and Insulin lispro – sliding scale before meals: BG 125-174 = 1 unit, BG 175-224 = 2 units, BG 225-274 = 3 units… Chelsea Warren Type 1 Diabetes Shadow Health SOAP Note
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