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Posted: March 16th, 2022
Episodic/Focused SOAP Note
Episodic/Focused SOAP Note
Scholar’s Title
Institutional Affiliation
Course
Professor’s Title
Date
Episodic/Focused SOAP Note
Affected person Info:
Ms. V, 71, F
S (subjective)
CC (chief criticism): Weak and drained on a regular basis. Coughing and sneezing and complications over the eyes and a chill. Frightened and can’t sleep at evening.
HPI (historical past of current sickness): Ms. V is a 71-year previous feminine of unknown ethnicity who involves the clinic complaining of weak spot and basic physique fatigue. She is complaining of coughing and sneezing and complications over the eyes and a chill. She is apprehensive and can’t sleep at evening.
Present Drugs:
HCTZ 25 mg day by day
Losartan 50mg day by day
Lexapro 10 mg day by day
MVI day by day
Calcium 18 mg day by day
Melatonin 6 mg nightly
Tylenol 10 mg each 6 hours as wanted for ache
Oxygen concentrator for shortness of breath
Inhaler at evening
Allergic reactions:
No recognized drug allergic reactions
PMHx:
Hypertension
Bronchial asthma
Soc and Substance Hx:
Non-smoker, no alcohol use, or illicit drug use. She is a retired housekeeper. She child sits her grandchildren three and 10 years previous. Grandparents and oldsters all died of previous age.
Fam Hx:
Grandparents and oldsters all died of previous age.
Grandchildren don’t have any important medical historical past.
Surgical Hx:
None
Psychological Hx:
No historical past of despair or anxiousness
Violence Hx:
None
Reproductive Hx:
Not sexually energetic. She is in menopause.
Immunization:
Vaccinated towards Covid-19 with two doses. Booster shot not but.
ROS (assessment of signs):
• GENERAL: Coughing and sneezing a chill. Lack of sleep as a consequence of fear.
• HEAD: Headache over the eyes.
• EENT (eyes, ears, nostril, and throat): No swelling or discharge, no blurred or double imaginative and prescient, no working nostril, and no sore throat.
• RESPIRATORY: Coughing.
• CV: Denies
• GI: Denies N/V/D
• GU: No modifications in urinary patterns.
• NEURO: NO dizziness however headache over the eyes. No modifications in physique motion and reminiscence patterns. No historical past of seizure or issues with coordination.
• LYMPH/HEME: Denies
• ENDOCRINE: Denies
• MUSCULOSKELETAL: Again ache reported.
• HEMATOLOGIC: No bleeding or anemia.
• LYMPHATICS: No historical past of splenectomy.
• PSYCHIATRIC: No historical past of despair.
• ENDOCRINOLOGIC: No studies of sweating or warmth intolerance.
• REPRODUCTIVE: Not sexually energetic.
• Allergic/immunologic: No historical past of rhinitis however she has bronchial asthma.
O (OBJECTIVE)
Bodily examination:
Important indicators: Temperature: 98.6, Pulse 78, RR 18, BP 112/72, Weight 172lb Top 5’10
Diagnostic outcomes:
Chest CT scans
Polymerase chain response (PCR) take a look at
CBC
A (Assessment)
Differential diagnoses:
Covid-19
Covid-19 impacts folks otherwise and the signs will be from delicate to extreme. Among the frequent signs embrace fever, fatigue, coughing, lack of scent and style (Felsenstein et al., 2020). Others embrace headache, sore throat, diarrhea, and pores and skin rash. Issue in respiratory and chest ache. The affected person is probably going affected by the situation as a consequence of her age and historical past of bronchial asthma (Felsenstein et al., 2020). She requires pressing Help to alleviate the chance of antagonistic outcomes.
J45. 909 Bronchial asthma
The second more than likely situation is bronchial asthma, as a result of historical past of an asthmatic situation. The affected person could also be affected by a reoccurrence of the illness. A step-wise methodology is used to deal with the situation to supply the wanted immunity towards the illness (Calzetta et al., 2021). Some signs embrace issue in sleeping, respiratory, exhaustion, and drowsiness.
J18. 9 Pneumonia
Sufferers with pneumonia embrace chest ache, coughing, fatigue, fever, nausea, and vomiting. Sufferers with bronchial asthma are more likely to endure from pneumonia, particularly through the chilly season (Calzetta et al., 2021). Acceptable interventions are important to alleviate the chance of loss of life.
J09. X2 Influenza
Influenza causes signs reminiscent of fatigue, coughing, fever, muscle and physique aches, and working nostril. Sufferers with bronchial asthma and Covid-19 are required to take a take a look at for influenza since it’s a deadly illness (Lansbury et al., 2019).
J12. 2 Parainfluenza
Parainfluenza refers to a household of viruses referred to as the human parainfluenza viruses (HPIVs). The illness is among the many Paramyxoviridae household (Lansbury et al., 2019). The signs embrace coughing, fever, working nostril, and rattling on the chest or again.
J81. zero Cardiogenic edema
Cardiogenic edema causes signs associated to Covid-19. People ought to get examined to verify the precise situation they’re affected by. Some signs embrace extreme shortness of breath, dizziness, anxiousness on mendacity down (Ingbar, 2019). The situation happens as a consequence of elevated stress within the coronary heart.
J67. 9 Hypersensitivity pneumonia
Hypersensitivity pneumonia causes shortness of breath, dry cough, fatigue, fever, and chest tightness. The situation happens as a consequence of an allergic response (Salisbury et al., 2017).
415.19 Pulmonary infarction
Pulmonary infarction is a situation that causes chest ache, physique weak spot, coughing, and fever. A CT scan is important for prognosis. Speedy remedy of the situation is important (Salisbury et al., 2017).
P (plan)
Remedy of Covid-19 is important as a consequence of escalating severity inside a short while. Regardless of the extent of severity, a pharmacological interventions is important. One of many important interventions is to examine the oxygen degree and pulse charge. Oxygen help is important if the affected person is experiencing issue in respiratory. The affected person ought to proceed taking present medicine and get medical help for bronchial asthma. The affected person ought to take ache killer to avert ache. If the signs persists, an MRI might be important in offering an in depth picture of the respiratory system.
Consuming a wholesome meal is important for the affected person to enhance the final health of the physique. Maintaining a healthy diet meals is a technique for sustaining physique health. It improves physique well being and prevents situations reminiscent of weak immunity. Weak immunity is a significant component that may complicate the physique’s well being and trigger stress on the physique.
A referral to a specialist in Covid-19 might be important for the restoration of the affected person. Working with a respiratory therapist can improve the probabilities of restoration.
It’s important to coach the affected person on the illness, function of maintaining a healthy diet meals, and keep away from transmission. A affected person ought to obtain oxygen help within the ICU if the situation worsens. Educating the affected person on adherence to the medicine is essential for restoration. The affected person ought to adhere to the medicine and report after two weeks.
The affected person ought to come for follow-up care after two weeks or earlier than relying on the restoration course of. The follow-up care could take even a month relying on the advance. Coordination of care among the many completely different specialists is important for restoration. Acceptable interventions ought to be taken relying on the result.
Reflection
The case research of the affected person is an eye-opener because it supplies new insights into the completely different diagnostic instruments and differential diagnoses. I discovered that accuracy within the provision of take care of sufferers with respiratory situations reminiscent of Covid-19 is important for restoration. I discovered that sufferers begin treating situations involving ache by taking over-the-counter medicine. An examination of the medicine a affected person is taking is important within the willpower of the medicine a affected person ought to begin taking.
An analysis of the affected person’s life-style is important for the restoration and prevention of comparable situations sooner or later. As an illustration, the affected person ought to keep away from heavy duties that contain straining the physique. The affected person ought to keep energetic since mattress relaxation shouldn’t be one of the best intervention for sufferers with Covid-19. It’s important to coach the affected person to get a booster shot, maintain masks on, and keep away from crowded locations. Going for a stroll is a technique of being energetic.
Throughout the provision of care, adherence to moral issues in nursing is important within the supply of patient-centered care. Sufferers of unknown ethnicity ought to obtain high quality care with none type of discrimination. Justice in nursing entails the remark of equity within the supply of care (McDermott-Levy et al., 2018). Veracity entails telling the reality to the affected person. As an illustration, telling the affected person in regards to the causes of Covid-19 and different situations that result in fever, ache, coughing, and fatigue will Help regulate life (McDermott-Levy et al., 2018). A nurse practitioner ought to make the most of one of the best information accessible in treating the affected person. nonmaleficence entails the supply of care whereas taking utmost care to keep away from hurt (McDermott-Levy et al.,2018). Moral follow is protected for sufferers and improves the extent of confidence in affected person outcomes.
References
Calzetta, L., Matera, M. G., Coppola, A., & Rogliani, P. (2021). Prospects for extreme bronchial asthma remedy. Present Opinion in Pharmacology, 56, 52-60.
Felsenstein, S., Herbert, J. A., McNamara, P. S., & Hedrich, C. M. (2020). COVID-19: Immunology and remedy choices. Medical immunology, 215, 108448.
Ingbar, D. H. (2019). Cardiogenic pulmonary edema: mechanisms and treatment-an intensivist’s view. Present opinion in important care, 25(four), 371-378.
Lansbury, L., Rodrigo, C., Leonardi‐Bee, J., Nguyen‐Van‐Tam, J., & Lim, W. S. (2019). Corticosteroids as adjunctive remedy within the remedy of influenza. Cochrane Database of Systematic Opinions, (2).
McDermott-Levy, R., Leffers, J., & Mayaka, J. (2018). Moral rules and pointers of worldwide well being nursing follow. Nursing outlook, 66(5), 473-481.
Salisbury, M. L., Myers, J. L., Belloli, E. A., Kazerooni, E. A., Martinez, F. J., & Flaherty, Ok. R. (2017). Analysis and remedy of fibrotic hypersensitivity pneumonia. The place we stand and the place we have to go. American journal of respiratory and demanding care medication, 196(6), 690-699.
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