Focused SOAP Note
Student’s Name
Institutional Affiliation
Course
Professor’s Name
Date
Patient Information:
F, 70, Male, Hispanic
S.
CC (chief complaint): Wounded and bleeding in the right arm after falling down the ladder while washing windows. Cannot speak words that make sense. Cannot remember his name and is dizzy.
HPI: Mr. Felipe is a 70-year-old male Hispanic who is brought to the clinic by the wife after he fell off the ladder while cleaning windows. He had fallen before without any significant injury. His wife and neighbor picked him up and dragged him to the car. His right arm is wounded and bleeding. Cannot speak words that make sense. The patient is in pain but the severity of pain is unknown.
Current Medications: No current medication. He takes whiskey to relieve pain.
Allergies: No known food or drug allergies.
PMHx: HTN.
Soc & Substance Hx: Takes whiskey to relieve pain. He does not smoke tobacco.
Fam Hx: Parents of old age. The children are healthy. No grandchildren.
Surgical Hx: No prior surgical procedures.
Mental Hx: No past diagnosis or treatment for mental illness.
Violence Hx: No history of violence. Lives peacefully with the neighbors.
Reproductive Hx: A father of two daughters. Married to one wife. It is not clear if he sexually active.
ROS:
GENERAL: No unintentional weight loss or gain, no weakness, fatigue, chills, or fever.
HEENT: Eyes: No visual loss, blurred vision or sclerae. Ears, Nose, Throat: No hearing difficulty, nasal congestion, sneezing, or sore throat.
SKIN: No itching, lesions, or rashes.
CARDIOVASCULAR: No chest pain, discomfort, or edema.
RESPIRATORY: No shortness of breath or cough.
GASTROINTESTINAL: No nausea, diarrhea, or abdominal pain.
GENITOURINARY: No burning sensation on urination.
NEUROLOGICAL: Patient complains of dizziness. No changes in bowel or bladder control.
MUSCULOSKELETAL: No muscle or joint pain.
HEMATOLOGIC: No anemia, bleeding or bruising.
LYMPHATICS: No enlarged nodes. No history of splenectomy.
PSYCHIATRIC: No history of mental illness such as depression.
ENDOCRINOLOGIC: No sweating at night or polydipsia.
REPRODUCTIVE: Not clear if the patient is sexually active with the wife.
ALLERGIES: No asthma, rhinitis, or hives.
O.
Physical exam:
VS: 165/95 H/R 76 R 18 T 98
Diagnostic results:
MRI is required to better view the head and chest and determine the cause of the symptoms.
A CT scan is vital to determine the extent of the injury of fracture of the bone in the hand.
A.
Differential Diagnoses:
Hypertension
The patient has been diagnosed with hypertension in the past but did not continue with the treatment due to cost constraints. The condition involves high pressure of the blood against the blood vessels (Benetos et al., 2019). Hypertension can lead to death if left untreated. Hypertension involves blood pressure above 140/90 while 180/120 is considered severe (Benetos et al., 2019).
Stroke
A stroke occurs when the blood pressure in the brain is interrupted preventing the essential tissues from receiving appropriate oxygen and glucose supply. Brain cells begin to die in minutes prompting an emergency surgery to counter the problem (Baracchini et al., 2020). Some of the warning signs of stroke include sudden numbness, sudden vision problems, dizziness, or loss of coordination (Baracchini et al., 2020).
Cerebrovascular disease
A cerebrovascular disease is a group of conditions that cause problems with blood flow in the brain. Stroke is the most common type of cerebrovascular disease (Goldberg et al., 2020). The symptoms include dizziness, confusion, numbness, loss of vision and balance, and nausea (Goldberg et al., 2020).
Hypertension stage 2
Patients with hypertension stage 2 are at risk of coronary disease. Patients with the condition will require urgent assessment by ensuring they follow strict dietary and lifestyle conditions (Althoff et al., 2019).
P.
The patient should be admitted at least for three days for appropriate monitoring. Monitoring patients with high blood pressure is effective in preventing stroke (Althoff et al., 2019). A follow-up program is essential after discharge. The patient should back to the evaluation after a week.
Painkillers are appropriate to ensure the patient is free from pain. Medication should include drugs to lower blood pressure.
A collaboration with different practitioners is vital for treatment. A cardiologist will be required to examine the patient regarding high blood pressure, a physical therapist is essential to help the patient with exercises, and a social worker will be required to support the patient address issues regarding treatment cost (Goldberg et al., 2020). A health educator is required to provide information to the patient about high blood pressure and hypertension.
Health promotion should include changes in lifestyle and diet. The patient should eat healthy meals and avoid a high amount of salt (Goldberg et al., 2020). The patient should stop taking whiskey. It is appropriate to exercise regularly and maintain body fitness. It is vital to avoid risky activities which can put him at risk of falling.
I learned that patients with high blood pressure can live without realizing the life-threatening nature of the condition. Providing appropriate support and education is vital for reducing the occurrences of the condition.
I was amazed that the patient has lived with high blood pressure without getting appropriate medical support. Elderly patients with high blood pressure are at risk of stroke.
References
Althoff, K. N., Gebo, K. A., Moore, R. D., Boyd, C. M., Justice, A. C., Wong, C., … & North American AIDS Cohort Collaboration on Research and Design. (2019). Contributions of traditional and HIV-related risk factors on non-AIDS-defining cancer, myocardial infarction, and end-stage liver and renal diseases in adults with HIV in the USA and Canada: a collaboration of cohort studies. The lancet HIV, 6(2), e93-e104.
Baracchini, C., Pieroni, A., Viaro, F., Cianci, V., Cattelan, A. M., Tiberio, I., … & Causin, F. (2020). Acute stroke management pathway during Coronavirus-19 pandemic. Neurological sciences, 41(5), 1003-1005.
Benetos, A., Petrovic, M., & Strandberg, T. (2019). Hypertension management in older and frail older patients. Circulation Research, 124(7), 1045-1060.
Goldberg, M. F., Goldberg, M. F., Cerejo, R., & Tayal, A. H. (2020). Cerebrovascular disease in COVID-19. American Journal of Neuroradiology, 41(7), 1170-1172.
