Episodic/Focused SOAP Note
Scholar’s Identify
Institutional Affiliation
Course
Professor’s Identify
Date
Episodic/Focused SOAP Note
Affected person Info:
Ms. V, 71, F
S (subjective)
CC (chief grievance): Weak and drained on a regular basis. Coughing and sneezing and complications over the eyes and a chill. Apprehensive and can’t sleep at night time.
HPI (historical past of current sickness): Ms. V is a 71-year previous feminine of unknown ethnicity who involves the clinic complaining of weak point 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 night time.
Present Medicines:
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 night time
Allergic reactions:
No identified drug allergy symptoms
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 fogeys all died of previous age.
Fam Hx:
Grandparents and fogeys all died of previous age.
Grandchildren haven’t any important medical historical past.
Surgical Hx:
None
Psychological Hx:
No historical past of despair or anxiousness
Violence Hx:
None
Reproductive Hx:
Not sexually lively. She is in menopause.
Immunization:
Vaccinated towards Covid-19 with two doses. Booster shot not but.
ROS (evaluate of signs):
• GENERAL: Coughing and sneezing a chill. Lack of sleep on account 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 operating 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 experiences of sweating or warmth intolerance.
• REPRODUCTIVE: Not sexually lively.
• 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 Peak 5’10
Diagnostic outcomes:
Chest CT scans
Polymerase chain response (PCR) check
CBC
A (Assessment)
Differential diagnoses:
Covid-19
Covid-19 impacts individuals in another way and the signs might be from delicate to extreme. A few of the widespread 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 respiration and chest ache. The affected person is probably going affected by the situation on account of her age and historical past of bronchial asthma (Felsenstein et al., 2020). She requires pressing Help to alleviate the danger of hostile outcomes.
J45. 909 Bronchial asthma
The second most definitely situation is bronchial asthma, because of the 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 offer the wanted immunity towards the illness (Calzetta et al., 2021). Some signs embrace issue in sleeping, respiration, 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 undergo from pneumonia, particularly throughout the chilly season (Calzetta et al., 2021). Applicable interventions are important to alleviate the danger of loss of life.
J09. X2 Influenza
Influenza causes signs akin to fatigue, coughing, fever, muscle and physique aches, and operating nostril. Sufferers with bronchial asthma and Covid-19 are required to take a check 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, operating 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 on account 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 on account of an allergic response (Salisbury et al., 2017).
415.19 Pulmonary infarction
Pulmonary infarction is a situation that causes chest ache, physique weak point, coughing, and fever. A CT scan is important for analysis. Speedy therapy of the situation is important (Salisbury et al., 2017).
P (plan)
Therapy of Covid-19 is important on account 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 stage and pulse fee. Oxygen help is critical if the affected person is experiencing issue in respiration. 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 will probably 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 overall health of the physique. Maintaining a healthy diet meals is a method for sustaining physique health. It improves physique well being and prevents circumstances akin to weak immunity. Weak immunity is a significant factor that may complicate the physique’s well being and trigger stress on the physique.
A referral to a specialist in Covid-19 will probably be important for the restoration of the affected person. Working with a respiratory therapist can enhance the possibilities of restoration.
It’s critical to teach the affected person on the illness, position 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 might take even a month relying on the advance. Coordination of care among the many totally different specialists is important for restoration. Applicable 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 totally different diagnostic instruments and differential diagnoses. I realized that accuracy within the provision of take care of sufferers with respiratory circumstances akin to Covid-19 is important for restoration. I realized that sufferers begin treating circumstances involving ache by taking over-the-counter medication. An examination of the medication a affected person is taking is important within the willpower of the medication a affected person ought to begin taking.
An analysis of the affected person’s way of life is important for the restoration and prevention of comparable circumstances sooner or later. As an example, the affected person ought to keep away from heavy duties that contain straining the physique. The affected person ought to keep lively since mattress relaxation will not be the very best intervention for sufferers with Covid-19. It’s critical to teach the affected person to get a booster shot, preserve masks on, and keep away from crowded locations. Going for a stroll is a method of being lively.
Through 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 includes the statement of equity within the supply of care (McDermott-Levy et al., 2018). Veracity includes telling the reality to the affected person. As an example, telling the affected person concerning the causes of Covid-19 and different circumstances that result in fever, ache, coughing, and fatigue will Help modify life (McDermott-Levy et al., 2018). A nurse practitioner ought to make the most of the very best information accessible in treating the affected person. nonmaleficence includes the availability of care whereas taking utmost care to keep away from hurt (McDermott-Levy et al.,2018). Moral apply is secure 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 therapy. Present Opinion in Pharmacology, 56, 52-60.
Felsenstein, S., Herbert, J. A., McNamara, P. S., & Hedrich, C. M. (2020). COVID-19: Immunology and therapy choices. Scientific 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 therapy of influenza. Cochrane Database of Systematic Assessments, (2).
McDermott-Levy, R., Leffers, J., & Mayaka, J. (2018). Moral rules and tips of worldwide well being nursing apply. Nursing outlook, 66(5), 473-481.
Salisbury, M. L., Myers, J. L., Belloli, E. A., Kazerooni, E. A., Martinez, F. J., & Flaherty, Okay. R. (2017). Prognosis and therapy of fibrotic hypersensitivity pneumonia. The place we stand and the place we have to go. American journal of respiratory and important care medication, 196(6), 690-699.
