week 3 soap note - nursingpapersmarket.com
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Running head: WEEK 3 SOAP NOTE 1
Week 3 SOAP Note
Student’s Name:
Institutional Affiliation:
WEEK 3 SOAP NOTE 2
Week 3 SOAP Note
Patient Information:
R.J., 67 years, Caucasian, Female.
Subjective
CC (chief complaint): the patient complains of increased shortness of breath and weakness. She
uses accessory muscle and pursed-lip breathing.
HPI: A 67-year-old Caucasian female complains of shortness of breath and weakness. She is
using accessory muscle and pursed-lip breathing. The patient also looks pale. She denies any
cough and has been receiving chemotherapy for left-sided breast cancer
Current Medications
Dexamethasone 4 mg 3 tabs PO bid on days 2 and 3 of cancer tx.
Metoclopramide HCL 10 M.G. 1 tab tid
Aprepitant 80 & 125 mg 1 tab daily one hour before chemo, 80 mg 1 tab on day 2 and 3 in the
AM (Nausea)
Metoprolol Succinate E.R. 50 mg 1 tab in the AM
Hyzaar 100-25mg 1 tab in the AM
Aspirin 81 mg 1 tab in the AM
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Hydralazine HCL 50 mg 1 tab with food bid
Diclofenac Sodium 50 mg 1 tab with food or milk bid prn pain
Hydrochlorothiazide 25 mg 1 tab in AM
Pravastatin Sodium 40 mg 1 tab QHS
Magnesium Oxide 400 mg 1 tab in the AM
Spironolactone 25 mg 1 tab in the AM
Gabapentin 100 mg 2 caps tid
Zofran 2 mg 1 tab daily
Allergies: No known allergies
PMHx: Reports a history of hypertension, hypercholesterolemia, lower extremity edema,
venous insufficiency, osteoarthritis, and left breast cancer. The patient has also undergone a total
hysterectomy.
SocHx: Denies smoking or alcohol use. Lives with adult children and a member of the Baptist
faith. The patient does not perform regular physical exercise because she uses a wheelchair.
Currently not working.
Fam Hx: Both parents are deceased. Mother had a history of breast cancer.
ROS:
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GENERAL: Reports fatigue. No reported weight changes or fever.
HEENT: Eyes: No reported visual complications. Ears, Nose, Throat: No reported hearing loss,
sore throat, sneezing, or congestion.
SKIN: The patient did not report any itching, rashes, or skin complications.
CARDIOVASCULAR: No reported chest pain or discomfort. Edema on the lower extremities.
RESPIRATORY: Shortness of breath and weakness.
GASTROINTESTINAL: No abdominal or bowel complications.
GENITOURINARY: Does not report any changes in urination patterns or genital
complications.
NEUROLOGICAL: Does not report dizziness or headache.
MUSCULOSKELETAL: No reported muscle, joint, or back complications.
HEMATOLOGIC: Reports feeling fatigued and dizzy. No abnormal bleeding.
LYMPHATICS: No enlarged nodes.
PSYCHIATRIC: No reported anxiety or depression.
ALLERGIES: No reported allergies
WEEK 3 SOAP NOTE 5
Objective
Physical exam:
Vitals:
Blood Pressure: 115/77
Heart Rate: 125
Temperature: 97.9
Respiration: 20
Oxygen Stat: 94%
Height: 5’ 4”
Weight: 120ibs
BMI: 20.6
General: Patient well-groomed, well-nourished, and cooperative with the exam. Appears alert
and fatigued.
Oral Cavity: Mucosa moist, light pink.
Throat: Clear.
Neck/Thyroid: Neck supple, full range of motion, no cervical lymphadenopathy.
Skin: No suspicious lesions, pale, warm, and dry.
Heart: Tachycardia
Lungs: Cleat to auscultation A/P bilaterally.
Abdomen: Flat, normal bowel sounds, soft, and non-tender.
Back: Full range of motion.
Extremities: Bilateral non-pitting edema to lower extremities.
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Neurologic: non-focal.
Psych: Alert, oriented, cooperative with the exam.
Diagnostic Results:
A computed tomography (C.T.) scan was conducted to check for pulmonary embolism
and cancer metastatic to the lungs. A CT scan involves the use of an X-ray to provide detailed
images of internal organs (Wegener, 2015). The CT scan showed that the patient had a
pulmonary embolism, and her breast cancer had spread to the lungs.
A lab test was also performed to test for chemotherapy-related anemia. The first test
involved a complete blood count (CBC). The assessment checks for hemoglobin and hematocrit
levels (McClatchey, 2014). It also counts the number of white blood cells, platelets, and red
blood cells in the blood (McClatchey, 2014). A CBC also measures the size of red blood cells.
The other procedure performed to test for anemia involved a physical exam where I listened to
the patient's heart to evaluate the heartbeat (McClatchey, 2014). The process also included
evaluating the lungs for irregular breathing and feeling the stomach to check for the liver and
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spleen size (McClatchey, 2014). The examinations tested positive for anemia, and the patient
required a blood transfusion.
Assessment
Differential Diagnoses
The patient, in this case, showed symptoms of shortness of breath and non-pitting edema
to the lower extremities. The symptoms may be caused by various conditions, as discussed
below.
Anemia. This is a condition that occurs due to the lack of enough red blood cells to
transport adequate oxygen to the body (Steensma, 2017). The symptoms of anemia include
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fatigue, pale skin, irregular heartbeat, weakness, and shortness of breath (Steensma, 2017). Other
symptoms that may include lightheadedness, and edema on the lower extremities (Steensma,
2017). Although edema is not a common symptom in anemia, it can occur due to insufficient
supply fluid circulation in the body (Steensma, 2017). Causes of anemia include the damage of
red blood cells or the loss of red blood cells (Steensma, 2017). Red blood cells transmit oxygen
from the lungs to other body parts. The damage of red blood cells thus hinders oxygen
transportation which might leading to breathing problems and fatigue (Steensma, 2017).
Pulmonary embolism. Pulmonary embolisms refer to blood clots in the arteries that
transport blood to and from the heart to the lungs (Tapson, 2018). The clots block normal blood
flow and may cause serious health problems such as low oxygen levels in the blood and lung
damage (Tapson, 2018). Pulmonary embolisms may travel to the lungs from a deep vein in the
legs. The clots occur when blood cannot flow freely through the leg (Tapson, 2018). Pulmonary
embolisms may also result from the use of medications such as birth control pills or recent
surgery (Tapson, 2018). The symptoms of the condition include edema, shortness of breath, and
a feeling of dizziness (Tapson, 2018).
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Lung cancer. This is a form of cancer that affects the lungs (Cooley, 2015). Symptoms
include chest pain, shortness of breath, headache, hoarseness, and edema (Cooley, 2015). The
risk factors of lung cancer are smoking or exposure to second-hand smoke and having a family
history of lung cancer (Cooley, 2015). Lung cancer can also occur after another form of cancer
has spread to the lungs (Cooley, 2015).
Heart failure. Heart failure is an illness that transpires when the heart muscle fails to
pump enough blood to the other body parts (Judge, Pawitan, Caldwell, Gersh, Kennedy, &
Participants, 2015). High blood pressure or narrowed arteries in the heart can weaken the heart
muscle making it unable to pump efficiently (Judge et al., 2015). Symptoms include shortness of
breath, fatigue, edema, irregular heartbeat, and chest pain (Judge et al., 2015).
Discussion
For the patient, in this case, the primary diagnosis was anemia. This is because the patient
showed most symptoms of anemia such as fatigue, shortness of breath, tachycardia, and edema
on the lower extremities. The anemia could be as a result of the destruction of red blood cells by
chemotherapy. However, the lab tests conducted showed pulmonary embolism and cancer
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metastatic to the lungs. Therefore, when offering treatment, I will also treat the patient for
pulmonary embolism and lung cancer.
Plan
Medication
Pulmonary embolisms can be fatal, so I will first administer thrombolytic drugs to reduce
the clots. Examples of thrombolytic drugs include urokinase and streptokinase (Tapson, 2018). I
will consult with my preceptor to determine the dosage and the specific drug suitable for the
patient.
Since the patient, in this case, have cancer, it will be challenging to treat her pulmonary
embolisms due to a risk of recurrent embolisms. Therefore, I plan to provide extended
anticoagulation as opposed to the usual three-month therapy offered to patients with no
additional complications.
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The patient also required a blood transfusion because she has anemia. However, she
declined so I will consult my preceptor on other possible interventions.
Alternative Therapies
The patient, in this case, has breast cancer which is spreading to other parts of the body
despite her receiving chemotherapy treatment. Therefore, she might need alternative therapies to
manage to improve her quality of life. Some alternative therapies I would recommend for the
patient include the following.
Exercise. I will create a moderate-intensity exercise plan with the patient which she
should perform regularly. The patient requires moderate levels of activity since she cannot
perform rigorous exercise due to shortness of breath. Gentle exercise will help in decreasing
fatigue and stress. It will also help to improve the quality of sleep, which is essential for
alleviating discomfort (Cassileth & Deng, 2014). When creating an exercise plan for this patient,
I will research on exercises suitable for individuals who use wheelchairs to ensure the exercises
meet her needs.
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Relaxation techniques. The patient will also require relaxation to help her relieve stress. I
will refer the patient to an expert who offers relaxation therapy. Relaxation will help to calm the
patient's mind and muscles, thus improving the quality of life (Cassileth & Deng, 2014).
Health Promotion Strategies
The patient, in this case, has a lifelong condition. Patient and family education is hence,
important in this case.
The patient had earlier rejected a blood transfusion suggestion. In case I will have not
found other ways to manage anemia, I will have to educate the patient on the blood transfusion
procedures and its significance in her treatment. I will also inform the patient of the need to
follow her treatment and the ways in which she can improve her quality of life.
The patient also requires an at-home oxygen therapy. Therefore, I will have to educate
the patient on how to handle an oxygen tank and the precautions to avoid accidents. I will also
inform the family on ways of caring for the patient and how to avoid accidents at home. I will
also discuss with the family the benefits of a healthy diet and regular exercise for the patient.
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Disease Prevention Strategies
The patient, in this case, has anemia resulting from chemotherapy. To prevent severe
complications, I will recommend an iron-rich diet. She also has difficulty breathing, so I will
advise the family members to avoid smoking near her.
Diagnostic Tests
After the initial treatment for pulmonary embolism, I will perform a C.T. scan to determine if
there are any clots left.
Referral
I will refer the patient to the oncology department for cancer treatment.
Follow up interval.
After the initial discharge, I will ask the patient to visit the hospital every week for a check-up.
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Reflection
The task assigned for this week was a bit challenging since this was my first time
conducting a diagnosis in real-life experience. However, I learned a lot from the activities. I first
learned how to collect patient history and perform confirmatory diagnostic tests using the
collected data. I did not know how to perform a C.T. scan, but through the guidance of my
preceptor, I was able to perform the test. I also learned that patients do not always accept the
suggested treatment. Therefore, as a medical practitioner, I should know how to communicate
with patients to win their trust. It was also confusing to diagnose the patient above since she had
multiple conditions. Nevertheless, through the help of my preceptor, I was able to make anemia
and pulmonary embolism diagnosis. From what I have learned, I think I need to conduct a
thorough history collection and physical examination the next time I will be making another
diagnosis.
________________________
Preceptor Signature and Date
Signature is REQUIRED for this assignment.
WEEK 3 SOAP NOTE 15
References
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Cassileth, B. R., & Deng, G. (2014). Complementary and alternative therapies for cancer. The
oncologist, 9(1), 80-89.
Cooley, M. E. (2015). Symptoms in adults with lung cancer: a systematic research
review. Journal of pain and symptom management, 19(2), 137-153.
Judge, K. W., Pawitan, Y., Caldwell, J., Gersh, B. J., Kennedy, J. W., & Participants, C. A. S. S.
(2015). Congestive heart failure symptoms in patients with preserved left ventricular
systolic function: analysis of the CASS registry. Journal of the American College of
Cardiology, 18(2), 377-382.
McClatchey, K. D. (Ed.). (2014). Clinical laboratory medicine. Lippincott Williams & Wilkins.
Steensma, D. P. (2017). Is the anemia of cancer different from chemotherapy-induced anemia?
Journal of Clinical Oncology, 26(7), 1022-1024.
Tapson, V. F. (2018). Acute pulmonary embolism. New England Journal of Medicine, 358(10),
1037-1052.
Wegener, O. H. (2015). Whole-body computerized tomography.
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