Posted: September 7th, 2022

Focused SOAP Note Sample

Focused SOAP Note

Scholar’s Identify
Institutional Affiliation
Course
Professor’s Identify
Date

Focused SOAP Note
Affected person Data:
Initials S, Age 68, Intercourse F
S (subjective)
CC: Intractable nausea and vomiting.
HPI: Sue is a 68-year-old feminine who involves the clinic complaining of intractable nausea and vomiting. The affected person complained that the situation has worsened for the final 5 weeks and 11-pound weight reduction. She experiences a boring and protracted headache. She has problem in focus and blurred imaginative and prescient. She takes Phenergan 12.5 PO each eight hours as wanted for nausea.
Present Medicines:
Xarelto Oral 20 MG 30 Tab(s) take one tab each day (C)
Anticoagulants
Metformin HCl Oral 500 MG 60 Tab(s) take 1 Tab(s) po twice a day
Antidiabetics
Lisinopril Oral 5 MG 90 Tab(s) take one tab po each day
Antihypertensives
Metoprolol Succinate ER Oral 25 MG take half tab ( 12.5 mg ) po each day
Beta Blockers
Atorvastatin Calcium Oral 40 MG 90 Tab(s) Take one pill orally each hour sleep (Antihyperlipidemics)
Vitamin C Oral 500 MG 1 Cap(s) orally each day
Nutritional vitamins(LS)Multivitamins Oral 1 Cap(s) orally each day
Multivitamins(LS)
Hydrocodone-Acetaminophen Oral 10-325 MG 1 Tab(s) orally each Four-6 hr as wanted for ache
Analgesics – Opioid
Furosemide Oral 40 MG 1 Tab(s) Twice Each day
Diuretics
Levetiracetam Oral 500 MG 1 Tab(s) Twice Each day
Anticonvulsants(LS)Gabapentin Oral 600 MG 1 Tab(s) Three Occasions Each day
Anticonvulsants
Phenergan 12.5 PO each eight hours as wanted for nausea
Allergy symptoms: NKDA
PMHx: Diabetes and coronary heart assault.
Soc and Substance Hx: No historical past of substance abuse and alcoholism.
Fam Hx: Diabetes and coronary heart assault.
Surgical Hx: Detrimental for historical past of surgical treatment.
Psychological Hx: Detrimental for historical past of psychological sickness, suicide ideation, nervousness, and melancholy.
Violence Hx: Detrimental for historical past of violence
Reproductive Hx: Data not obtainable in regards to the reproductive well being and variety of youngsters.
ROS (evaluate of signs):
GENERAL: No fever, fatigue, or sudden weight reduction or achieve.
HEENT:
• Eyes: Blurred imaginative and prescient.
• ENT: No discharge, nasal congestion, or sore throat.
SKIN: No pores and skin rashes, itching, or lesions.
CARDIOVASCULAR: Detrimental for chest ache and discomfort.
RESPIRATORY: No coughing or respiratory difficulties.
GASTROINTESTINAL: Constructive for nausea and vomiting.
GENITOURINARY: No burning sensation whereas passing urine. Data shouldn’t be obtainable in regards to the final menstrual interval.
NEUROLOGICAL: No numbness or tingling, issues in bowel management, headache, and dizziness.
MUSCULOSKELETAL: Detrimental for again or muscle ache.
HEMATOLOGIC: No bleeding.
LYMPHATICS: No enlarged nodes.
PSYCHIATRIC: No suicidal ideas or stress.
ENDOCRINOLOGIC: No historical past of sweating, polyuria or polydipsia.
REPRODUCTIVE: No latest being pregnant. She is previous little one bearing age. She shouldn’t be sexually lively.
ALLERGIES: NKDA
O (goal)
Bodily examination:
Very important indicators: T 98.7F orally, 122/82, RR 18, P 74 common, wt 100lbs, ht Four’9, BMI 20.
Basic: alert and oriented to time and place.
HEENT: Oronasopharynx is evident, no discharge, no nasal congestion, and no sore throat.
Neck: Carotid no bruit.
Chest/lungs: CTA AP&L.
Coronary heart: No palpitations.
ABD: Detrimental for suprapubic tenderness.
Musculoskeletal: Symmetrical muscle development and improvement.
Neuro: CN II-XII and DTR intact.
Pores and skin/lymph: No edema or lesions.
Diagnostic outcomes:
There isn’t any particular diagnostic check to find out migraine. A number of the widespread assessments embody MRI and CT scans are important in ruling out different situations that may have an effect on current comparable signs (Wijeratne et al., 2019). MRI examines tumors, stroke, bleeding, and infections.
A evaluate of the medical historical past, together with complications, location and kind of ache, and frequency of complications, will help practitioners diagnose migraine (Wijeratne et al., 2019).
A (Assessment)
Differential diagnoses:
Migraine: Migraine is a neurological illness that presents numerous signs. One of many main signs is extreme throbbing ache on the aspect of the pinnacle. The ache triggers vomiting and nausea (Becker, 2017). Individuals with migraine expertise gentle imaginative and prescient loss or sensitivity to mild. The signs intervene with each day actions. Preventive and pain-relieving treatment will help alleviate the ache. The causes of migraines embody stress, vibrant lights, and odor (Becker, 2017). Modifications or disruption of the mind chemical compounds can set off migraines.
Subarachnoid hemorrhage: The situation outcomes from bleeding across the mind. It’s a life-threatening situation that may set off signs similar to complications, vomiting, and nausea (Sergeev, 2018). A number of the causes of the situation embody aneurysm, AVM, or head harm. It could trigger incapacity or loss of life.
Intracranial mass: Mind tumor is a development that happens uncontrollably. It may be cancerous or non-cancerous. One of many widespread complications is a headache. Different signs embody nausea, vomiting, lack of imaginative and prescient, or blurred imaginative and prescient (Sergeev, 2018). Therapy of the situation consists of chemotherapy, radiation, or surgical procedure.

P (plan)
The situation would require referral to specialists who will diagnose the situation and supply applicable treatment. The referral offers sufferers a possibility to obtain high quality therapy.
Therapy of the situation would require numerous life-style adjustments, together with sleep hygiene, stress administration, food regimen modification (Minen et al., 2016). Sufferers ought to take preventive drugs to stop and relieve ache. Among the best drugs to stop and relieve ache is Triptans 25mg. The medication are efficient in addressing a number of migraine signs (Burch, 2019). The affected person ought to start with one pill each day for 3 days. The aim is to evaluate the negative effects and effectiveness of the medication (Burch, 2019). The affected person ought to come again after three days to find out if the drug needs to be modified or adjusted.
Affected person training about migraines will contain educating the affected person in regards to the causes of the situation. It is going to be essential to spotlight the approach to life adjustments that can forestall the situation from occurring (Burch, 2019). Affected person training is important to vary the beliefs about migraines.
The affected person ought to come for comply with up visits to evaluate the extent and frequency of signs (Minen et al., 2016). Throughout the follow-up visits, the affected person will clarify their expertise after life-style adjustments. The data is important in growing a dependable therapy plan to suppress the signs.
Reflection
I realized that migraines couldn’t be recognized with out a number of diagnostic assessments. The aim of the diagnostic assessments is to rule out different doable situations. I realized that aged sufferers require a pleasant method to the bodily examination. The sufferers can expertise different well being situations which will have an effect on their well being considerably. I realized that neurological situations, similar to migraines, require life-style adjustments as the most effective therapy approaches.
Aged sufferers experiencing weight reduction require rapid care to cease weight reduction. Lack of weight amongst older adults can undermine the restoration course of or set off extra well being situations. Physique weak spot can result in weak immunity that may trigger different well being situations.
The cultural background of a affected person can undermine their restoration. Sufferers from poor backgrounds can expertise challenges in combating migraines. For instance, foul odor, noises, poverty, and unfavorable beliefs can undermine therapy plans and restoration adherence. Some group beliefs argue that conventional treatment is efficient for the therapy of migraine. It is very important educate the affected person to get rid of unfavorable beliefs.

References
Becker, W. J. (2017). The prognosis and administration of continual migraine in main care. Headache: The Journal of Head and Face Ache, 57(9), 1471-1481.
Burch, R. (2019). Migraine and tension-type headache: prognosis and therapy. Medical Clinics, 103(2), 215-233.
Minen, M. T., Loder, E., Tishler, L., & Silbersweig, D. (2016). Migraine prognosis and therapy: a data and wishes Assessment amongst main care suppliers. Cephalalgia, 36(Four), 358-370.
Sergeev, A. V. (2018). Migraine’masks’: differential prognosis of acute headache. Journal, 118(1), 96.
Wijeratne, T., Tang, H. M., Crewther, D., & Crewther, S. (2019). Prevalence of migraine within the aged: a narrated evaluate. Neuroepidemiology, 52(1-2), 104-110.

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