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

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 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…

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