Complete SOAP Observe #three
Variety of sources: four
Paper directions:
Practicum Expertise – Complete SOAP Observe #three
After finishing this week’s Practicum Expertise, assessment the Complete SOAP Observe Exemplar and Template on this week’s Sources, and replicate on a affected person who introduced with musculoskeletal problems or ache. Describe the affected person’s private and medical historical past, drug remedy and coverings, and follow-up care.
All SOAP notes have to be signed and every web page have to be initialed by your preceptor. If you submit your SOAP Notes, it’s best to embody the whole SOAP Observe as a Phrase doc and pdf/photos of every web page that’s initialed and signed by your preceptor. You will need to submit your SOAP Notes utilizing SAFE ASSIGN.
Age 73 Male , J.S.
DX HTN, Arthritis,
Ambulate with cane
Very important indicators 134/76 18 97.three 97% O2 SAT HT 5’6 217 WT
Ache medication hydrocodone 5/325mg each 6 hours as wanted for ache, ache stage reported three after med aid and vary 6to Eight on most days
Affected person acquired flu immunization
No allergic reactions
No pores and skin openings , poor turgor
Resp , no SOB lungs clear on asculation
===
Complete SOAP Template
Title
Educational Establishment
Complete SOAP
Affected person Initials: ___J.S____ Age: ___73____ Gender: ___M____
SUBJECTIVE DATA:
Chief Criticism (CC): Chest ache and issue in respiration.
Historical past of Current Sickness (HPI): J.S is a 73-year-old male who presents to the clinic with completely different signs together with chest ache and issue in respiration. He signifies the signs have been persisting for the final one week. He’s involved that the situation could also be as a result of malfunction of the guts. He complains of gentle issue in respiration. He states he didn’t take his remedy for the final week. He denies any life-style adjustments. He has a household historical past of hypertension, myocardial infarction, and stroke. His mom died 20 years in the past after succumbing to a stroke. The affected person signifies the severity of the ache is three on regular days and 6-Eight throughout some days.
Medicines: Hydrocodone 5/325mg each 6 hours and as wanted.
Allergic reactions: NKDA
Previous Medical Historical past (PMH): He has suffered from diabetes since he was 50 years however the situation is nicely managed. He has no historical past of kid sickness or hospitalization. He’s not sexually energetic since his spouse died 10 years in the past.
Previous Surgical Historical past (PSH): He has been handled for a damaged arm at age 43. He was admitted to Dr. Bakker, Grand Haven, MI. He has not skilled a coronary heart situation previously.
Sexual/Reproductive Historical past: The affected person is heterosexual however not sexually energetic.
Private/Social Historical past: He denies smoking or taking medicine together with ETOH. He engages in common train at an area sports activities membership.
Immunization Historical past: All immunizations are updated. Lately, he acquired a flu vaccine. He acquired the 2 vaccines at Dr. Bakker, Grand Haven, MI.
Vital Household Historical past: The 2 dad and mom handed on 20 years in the past. His father was affected by hypertension whereas his mom died of cardiac arrest. His father was additionally diabetic. He has two wholesome siblings. He lives in the identical neighborhood together with his sons who’re aged 40 and 45. The 2 sons are wholesome with no vital medical situation.
Way of life: The affected person is a retired mechanic who resides off his pension. He attends a church service each Sunday at an area Pentecostal church. He hangs out together with his pals at an area restaurant.
Overview of Techniques:
Common: The affected person is alert, cooperative, and in good well being situation. He has a pointy reminiscence and solutions all questions appropriately by narrating previous occasions. He has unintentional weight adjustments, fever, or chilly.
HEENT: The affected person has no listening to issues, imaginative and prescient impairment. He wears eyeglasses. His final eye and ear examination have been carried out three months in the past. His hears haven’t any discharge, an infection, or abnormalities. His scent is unblemished. He has no operating nostril or nasal congestion. His oral mucosa is clear and intact. His final dental examination was 6 months in the past. He has no dental issues. He swallows meals with no difficulties.
Neck: Diffuse involvement of his scalp and preauricular cheek.
Breasts: He has no lesions or rashes.
Respiratory: No respiration issues. He has a symmetrical diaphragmatic tour. No respiratory issues or a household historical past of bronchial asthma.
Cardiovascular/Peripheral Vascular: He studies gentle discomfort within the chest, palpitations, dyspnea, orthopnea, edema in addition to claudication.
Gastrointestinal: The affected person studies no nausea, belly ache, or reflux. He has regular bladder patterns.
Genitourinary: He studies regular urine patterns and no historical past of incontinence.
Musculoskeletal: No historical past of gout or arthralgia.
Psychiatric: The affected person has no historical past of melancholy or sleep problems. He denies any suicidal ideas.
Neurological: He has no historical past of seizures, dizziness, syncopal episodes. or poor coordination.
Pores and skin: He has no rashes, bruises, or wounds. He has no itching or bleeding pores and skin.
Hematologic: He has no historical past of blood dysfunction.
Endocrine: No endocrine issues.
Allergic/Immunologic: NKDA.
OBJECTIVE DATA
Bodily Examination:
Very important indicators: 134/76 18 97.three 97% O2 SAT HT 5’6 217 WT.
Common: A&O *three NAD, dressed decently, acutely aware concerning the atmosphere, however seems barely uncomfortable.
HEENT: Plaque involvement diffusely on the central face. Diffuse involvement of his scalp.
Neck: Carotids no bruit.
Chest/Lungs: CTA AP&L.
Coronary heart/Peripheral Vascular: RRR with out murmur, rub, gallop, pulses +2.
Stomach: No organomegaly, diffuse, or rebound.
Genital/Rectal: Deferred.
Musculoskeletal: Symmetric muscle improvement, all muscle teams’ power 5/5.
Neurological: CN I-IV grossly intact and DTR intact.
Pores and skin: No bleeding, discoloration, discharge, or raised erythematous plaques.
ASSESSMENT:
Lab Exams and Outcomes: SAO2 – 97%.
EKG: Irregular coronary heart price and rhythm.
Differential Analysis (DDX):
Myocardial infarction – The situation happens when the blood stream decreases or stops inflicting injury to the guts muscle tissues as a result of formation of clots. It results in chest ache and discomfort. The ache happens on the shoulder, arm, neck, or jaw (Akbar et al., 2017). Myocardial infarction can happen in varied varieties that may pose completely different dangers to the well being of a affected person. It is among the possible circumstances as a result of similarity of the signs.
Hypertension – It’s a situation that entails hypertension. It happens if the stress is above 140/90 a affected person is at better danger (Anderson & Morrow, 2017). The signs contain chest ache and issue in respiration. Sufferers require remedy to decelerate the stress. The affected person is much less prone to have hypertension because the blood stress is 134/76. Nonetheless, they proceed taking remedy because the danger of hypertension might nonetheless be excessive.
Coronary heart failure – The situation is also called congestive coronary heart failure. It happens when the muscle tissues within the coronary heart don’t pump as they need to (Reed et al., 2017). One of many main causes is narrowed arteries. The affected person ought to proceed taking common assessments to make sure they’re out of danger of coronary heart failure.
Analysis:
Myocardial infarction is the most certainly situation that the affected person is affected by.
Therapy Plan:
The affected person ought to take Beta blockers 50mg twice a day (Kawamura et al., 2018). The affected person ought to embrace extra time to relaxation. He ought to come again for an evaluation after three days.
Well being Promotion:
The affected person ought to take extra relaxation and eat wholesome meals. He must also keep away from meals with excessive quantities of salt or ldl cholesterol. It is usually advisable for the affected person to scale back weight since sufferers can expertise worse signs if they’re chubby (Berliner et al., 2016). The affected person additionally engages in common workouts that may enhance their physique health. It is usually acceptable to keep away from alcohol and smoking since they’ll improve the danger of an infection.
Illness Prevention:
The affected person ought to keep away from aggravating conditions or strenuous workouts that may set off an increase in blood stress. He ought to proceed taking the remedy as prescribed to keep away from relapse. He ought to keep away from aggravating circumstances that may trigger the guts to overwork (Reed et al., 2017). The affected person ought to get speedy medical assist in the event that they expertise any irregular signs.
REFLECTION:
The scientific expertise supplies a studying alternative for finishing up a complete examination of a affected person with a number of circumstances. The expertise helped me to think about the relationships between varied well being circumstances and their impact on the most certainly situation. An evaluation of the affected person’s household and medical background was additionally informative. For instance, figuring out a hyperlink between household historical past and the current situation was fascinating and informative. Moreover, it was fascinating to look at different elements of the physique their performance together with ears, nostril, neck, and eyes. All the data was essential whereas finishing up the differential analysis and narrowing down on the precise circumstances the affected person may very well be affected by.
Sooner or later, I want to research varied well being circumstances of sufferers, particularly amongst geriatric sufferers and their affect on basic well being. It is usually necessary to review the dangers that ambulating a affected person’s expertise that may result in critical well being circumstances. I additionally need to offer high quality info to sufferers to assist them make the suitable choices for his or her well being. For instance, life-style adjustments can result in a rise in high quality well being amongst geriatric sufferers.
I uphold the findings of the preceptor because the info offered is much like the signs the affected person is affected by. The signs point out the probability of myocardial infarction. Proof additionally means that the affected person ought to make life-style adjustments to enhance their well being situation. For instance, there’s a want to enhance on every day workouts whereas being cautious concerning the meals. The precautions will enhance the well being of the affected person. Moreover, the affected person ought to come again for additional examination after three days. If the signs are worse, the affected person could be admitted to obtain shut consideration from the healthcare practitioners.
References
Akbar, N., Digby, J. E., Cahill, T. J., Tavare, A. N., Corbin, A. L., Saluja, S., … & McNeill, E. (2017). Endothelium-derived extracellular vesicles promote splenic monocyte mobilization in myocardial infarction. JCI Perception, 2(17).
Anderson, J. L., & Morrow, D. A. (2017). Acute myocardial infarction. New England Journal of Drugs, 376(21), 2053-2064.
Berliner, D., Schneider, N., Welte, T., & Bauersachs, J. (2016). The differential analysis of dyspnea. Deutsches Ärzteblatt Worldwide, 113(49), 834.
Kawamura, R., Saiki, H., Tada, H., & Hata, A. (2018). Acute myocardial infarction in a 25-year-old girl with sitosterolemia. Journal of Medical Lipidology, 12(1), 246-249.
Reed, G. W., Rossi, J. E., & Cannon, C. P. (2017). Acute myocardial infarction. The Lancet, 389(10065), 197-210.
