Watch the following videos, then complete the required assignment. Review the document in Course Resources for instructions on accessing the videos. 14:53 Upon completion of watching the video write up the scenario into a SOAP format. Is there anything you would do differently on your plan? 26:53 Upon completion of watching the video write up the scenario into a SOAP format. Is there anything you would do differently in your plan?
SOAP FORMAT ASSIGNMENT
Scenario 1: 14:53 Video
Subjective:
In the video, the patient presents with a chief complaint of severe abdominal pain. The pain is described as intermittent and localized in the lower right quadrant. The patient denies any additional symptoms but expresses concern that the pain may be indicative of appendicitis.
Objective:
Upon examination, the physician notes tenderness in the lower right quadrant upon palpation. The patient’s vital signs are within normal limits, and the rest of the physical examination is unremarkable. The physician orders further tests to confirm the diagnosis.
Assessment:
Based on the patient’s history, physical examination findings, and concern for appendicitis, the physician suspects acute appendicitis and plans to proceed with diagnostic imaging.
Plan:
The physician orders the following:
1. Complete blood count (CBC): to assess for leukocytosis, which may indicate inflammation.
2. Appendicitis scoring system assessment: to determine the likelihood of appendicitis based on specific signs and symptoms.
3. Ultrasound: to assess for signs of appendicitis such as an enlarged appendix, fluid collection, or appendicolith.
4. Consultation with a general surgeon: to discuss potential surgical intervention if appendicitis is confirmed.
Reflection:
Upon reviewing the scenario, one thing I would consider doing differently is obtaining a urine analysis (UA) or urine pregnancy test. Although not mentioned in the video, these tests can help rule out other possible causes of abdominal pain, such as urinary tract infection or ectopic pregnancy. By including these additional tests, the diagnostic process could be more comprehensive and potentially rule out other potential diagnoses.
Scenario 2: 26:53 Video
Subjective:
In the video, the patient presents with a chief complaint of persistent cough, which has been worsening over the past few weeks. The cough is associated with yellow sputum production and occasional shortness of breath. The patient denies any chest pain or fever but expresses concern about the prolonged nature of the cough.
Objective:
Upon examination, the physician notes diminished breath sounds on the left side of the chest. The patient’s vital signs are stable, and the rest of the physical examination is unremarkable. The physician suspects a possible lung infection and plans further evaluation.
Assessment:
Based on the patient’s history, physical examination findings, and concern for a lung infection, the physician suspects pneumonia and plans to proceed with diagnostic testing.
Plan:
The physician orders the following:
1. Chest X-ray: to assess for signs of pneumonia, such as consolidation or infiltrates.
2. Complete blood count (CBC) with differential: to assess for leukocytosis and a left shift, which may indicate an infection.
3. Sputum culture and sensitivity: to identify the causative organism and guide antibiotic therapy.
4. Consultation with a pulmonologist: to evaluate the need for specialized care or intervention.
Reflection:
Upon reviewing the scenario, one thing I would consider doing differently is performing a rapid influenza test. Influenza can present with symptoms similar to pneumonia, such as cough, fever, and sputum production. By ruling out influenza, the physician can ensure that the correct diagnosis is made and appropriate treatment is initiated. Additionally, identifying the influenza strain can help guide antiviral therapy if necessary.
In conclusion, both scenarios illustrate the importance of gathering subjective and objective information, formulating an accurate assessment, and developing an appropriate plan. While the provided plans in the videos were sound, there were additional considerations that could have enhanced the diagnostic process and ensured a more comprehensive evaluation. The reflection portion of this assignment allows for critical thinking and identification of potential improvements in the diagnostic plan.