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SOAP Note on Patient Seen in the Practicum Setting

Subjective Data

  1. Chief Complain (CC): Mrs. Denise Sheila is a thirty two year old single mum. On the third of this month she presented herself with complains concerning her health. She complained of coughing, and a persistent chest discomfort that became more painful at night. She also complained of wheezing.
  2. History of Present Illness (HPI): About three months ago, Mrs. Denise visited a health facility and complained about a persistent cough. She was administered with drugs to control the situation. From then she was okay until recently when the cough started and coupled up with more signs and symptoms.
  3. Last Menstrual Period (LMP): Mrs. Denise had her LMP the previous month.
  4. Allergies: Mrs. Denise is allergic to dust. When she is exposed to dust, she sneezes a lot. She is not allergic to things like pollen grains and animal fur, in fact she claims to have a garden at her home and she also keeps animal pets.
  5. Past Medical History: Mrs. Denise has had a rather rough medical history. A few years back she was diagnosed with syphilis, a sexually transmitted infection. It was treated and she managed to recover fully. She has had an unidentified problem with her left leg over a long period, a situation that she says she has been able to learn how to live with. Her left hip joint slightly disjointed and joined back again. It was said that a tendon around the joint was affected but would recover with time. She incurred in her late teenage during a terminal injury. Apart from these complications, recently before this visit she has had lots of chest pain and persistent coughing.
  6. Family History: She was brought up with both parents, his father was a smoker. He was in his late years diagnosed with lung cancer of which he unfortunately succumbed to two years later. The diagnosis was made when the malignant tissue had already spread. It was not able to be repaired. The mother was an alcoholic but did it with moderation. She has been diagnosed with liver complications that are being managed today. Her mother was once diagnosed with upper respiratory infections that were then controlled.

The family history points out a myriad of serious medical complications. This points out to the fact that probably, the family does not put much importance to its health practices. Another reason is that they do or practice risky behaviour that exposes them to those infections. Mrs. Denise is today a single mum with a daughter who unlike what is expected is healthy (Knuston, & Braun, 2002).

  1. Surgery history: Mrs. Denise has undergone surgery. This was when she was delivering her daughter; she had a caesarean section done on her because of the unidentified terminal injury on her left leg. The injury she had also affected her hip bone and slightly extended to the pelvic. She opted for the caesarean section upon the advice given to her by her gynaecologist. It would have been dangerous or rather risky to attempt due to that condition. However, after the caesarean section was done on her she has recovered fully from that and no other complication have occurred resulting or related to the surgery.

Apart from the caesarean section, Mrs. Denise has had no other surgery even though she ought to have undergone a corrective surgery on her leg. She never under went through it due to the prevailing circumstances at that time. Furthermore, as she puts it would have been riskier exposing herself to that particular surgery.

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  1. Social History: Mrs. Denise has a vast social history. She does alcohol but not frequently. She says that she does it on a weekly basis not daily. She emphasizes on the fact that she takes only small amounts and occasionally completes one full bottle. She is also a smoker, though not to be a regular smoker; it is evident that she has been doing it for quite sometimes. She was introduced to the act with her peers, while still in college. She had once quit smoking, but the kind of work she does, as she puts it demands that she also smokes to flow with the rest. Apart from smoking, she does not engage in other abusive substances.
  2. Health Maintenance: From the health records that she posses, Mrs. Denise has undergone all immunizations that she ought to. The last time she visited a health facility for general health check up was three years ago, ever since she has not had a chance to go for a health maintenance check.
  3. Lifestyle Patterns: Mrs. Denise has no any spiritual beliefs that she firmly holds onto. She is an open-minded person when it comes to religion, because of the manner in which she grew up. Her family, just like many other families around did not hold the spiritual part of life with such importance. Mrs. Denise behaviour is a risky one as far as medical factors are considered. It can be described as a risky behaviour that exposes one to medical complications. Traditional practices carried out by Mrs. Denise do not pose risks to her medically if they are carried out in the right manner. The practice she carries out includes tattoos and has done lots of piercing on her body. Piercing should be carried out in professional facilities. Things like using the same piercing instruments among different clients are among the risk part of this practice. Furthermore, the possibility of infections at the point where the piercing was made. However, Mrs. Denise seems to have undergone these practices safely.
  4. Current Medication: Since the last complains she had about coughs, she has not had any complications that did warrant her to take medicines until today. Her terminal leg injury is a slight one and does not require frequent medication as one would expect. Otherwise, she has no other illness to cause her be on regular medication on a daily basis.
  5. Review of System: In this review, her lungs were found to be painful as she has illustrated in CC. Her skeletal system was slightly weak this is due to her terminal leg injury. However, this did not pose a great threat because from the diagnosis, it was better when it remained in that state. She did not completely complain about anything that suggests her heart was problematic in CC, but as it is the case her respiratory system was going through a lot. This also calls for diagnosis of the heart just to alleviate any fears and suspicions that result. Since she has been on alcohol for quite some time, the liver would be an organ for interest for any medical personnel. Therefore, the liver is of essence in this review so as to avert on any looming medical danger ahead.

Objective Data

Vital signs: she appeared generally healthy, height: she is 1.5m tall, weight: 66 kg, temp. 36.4 C.

General Appearance: she generally appeared, healthy.

Heart beat: 82 bpm.

Assessment

Differential Diagnosis

The diagnosis tests used were as follows.

Lung Function Test – This is a test used to determine the efficiency of lung function. This test determines the speed at which your lungs blow air and the delivery of oxygen into blood. It also measures the amount of inhalation (Sheperd, 1995). These measures compared with that of other people essentially it helps to measure ones range. The reason for carrying out this test was to find out the possibility of pulmonary fibrosis, and most importantly to be able to compare the ranges of her lungs (Knuston, & Braun, 2002).

The spirometer is used to carry out these measurements. Secondly, is the plethysmography test a test that determines the remaining air in the lungs after a cycle of in and out breathing (National Prescribing Centre, 2006).

  1. Lipoprotein Panel. This is a blood test that can help show whether the patient is at risk for a heart related complication. This test gives information about a patient’s total cholesterol, LDL (“bad”) cholesterol. It is the main source of cholesterol build up that would cause blockage in the arteries. The test also gives information on HDL “good” cholesterol and triglycerides. When abnormal cholesterol and triglyceride levels are obtained, that would be an indicator of high risk of coronary related diseases (National Prescribing Centre, 2006).
  2. The third test is the Chest X ray. This test was done to find the cause of the symptoms that the patient had presented in CC. Apart from that reason, the X ray help to diagnose conditions such as heart failure, lung cancer especially given that our patient is a smoker. They are used before surgery to look at the structures (National Prescribing Centre, 2006).

Medical Diagnosis

The medical diagnosis made was that Mrs. Denise had contracted bronchitis a respiratory infection. This infection had manifested itself earlier and just passed as common cold.

Plan

Treatment

I prescribed antibiotics to Mrs. Denise to counteract bacterial threats that I thought would be behind the cough. They were also meant to reduce the pain she felt. I recommended cough syrup for five days, because of the tendency of the cough to persist especially during the night, I advised that she gets dextromethorphan a cough suppressant. The drug works well to relieve one from persistent cough. To counter her bronchitis, I prescribed prednisone 2 bd *3/7 and doryx 3tds daily. Both are taken orally for up to 15 days. The medical diagnostic ICD 10 used is 491.1 and 446.0 (Sheperd, 1995).

Diagnostic testing used in this testing was accurately done and to the point. The test enabled us to do away with any doubts that the heart was also affected. Since from the test results, the heart was in the right condition. This was shown by the X ray taken. The patient on CC did not highlight of any colored mucus whenever she coughed. This did not warrant for a sputum test as one would expect. It occurs therefore from the results found that Mrs. Denise had her bronchitis detected in its early stages.

Health promotion and maintenance: Mrs. Denise was advised on the importance of going for health check ups and health promotion activities. Such activities would enable her to detect any infections early enough hence making them manageable. She was also reminded to engage in health promoting activities such as an appropriate diet with not too much fat component. Such would go a long way in ensuring that her health is in good condition. She was also discouraged from engaging in smoking as it would be a lead to engaging in other drugs which may put her health at risk (National Prescribing Centre, 2006).

Cultural and lifespan considerations: from what was observed and learned from our patient, Mrs. Denise, cultural practices and considerations are an important factor of ones health. Having said that, it is then of paramount importance to observe practices that promotes healthy living free from diseases. Practices that make someone susceptible to contracting infection are not good cultures. In connection to this, she was advised on using sterilized equipment whenever she wanted to do another piercing.

Follow up plans. After the successful medical session with Mrs. Denise, she was booked for a day fifteen days after she was treated. Within that period she will have cleared with taking the medicines. After this period of time, it will be appropriate to review how far she would have gone with the treatment. The results of the follow up will determine the steps to be taken. Follow up CPT code used 99203.