Pick any Acute Disease: Use Guillain-Barré syndrome . Follow the Soap Note Rubric as a guide Use APA format and must include minimum of 2 Scholarly Citations. Soap notes will be uploaded to Moodle and put through TURN-It-In (anti-Plagiarism program) Copy paste from websites or textbooks will not be accepted or tolerated. The use of templates is ok, but the Patient History, CC, HPI, The Assessment and Plan should be of your own work and individualized to your made up patient.

SOAP Note

Patient: John Doe
Age: 45
Gender: Male
Chief Complaint (CC): Lower limb weakness and tingling
History of Present Illness (HPI): The patient, a 45-year-old male, presents with a 2-week history of progressive weakness and tingling sensations in his lower limbs. The symptoms started in his feet and gradually progressed up to his knees. He reports difficulty walking and trouble with balance. The patient denies any preceding illness or febrile illness. There is no history of recent travel, vaccination, or exposure to toxins. No significant family history of neurological disease is reported. The patient denies any recent gastrointestinal or respiratory illness.

Review of Systems (ROS):
– Neurological: The patient reports muscle weakness, tingling, and difficulty with coordination in his lower limbs. No other neurological symptoms are reported.
– Musculoskeletal: The patient denies any joint pain or stiffness.
– Gastrointestinal: The patient denies any gastrointestinal symptoms such as abdominal pain, diarrhea, or vomiting.
– Respiratory: The patient denies any respiratory symptoms such as cough, shortness of breath, or chest pain.
– Cardiovascular: The patient denies any chest pain, palpitations, or edema.
– Genitourinary: The patient denies any urinary symptoms such as frequency, urgency, or burning.
– Dermatological: The patient denies any skin rashes or lesions.
– Psychiatric: The patient denies any mood changes, anxiety, or depression.
– Hematological: The patient denies any history of bleeding or anemia.
– Endocrine: The patient denies any changes in weight, heat or cold intolerance, excessive thirst, or excessive urination.

Past Medical History (PMH):
The patient’s past medical history is significant for hypertension, controlled with medication.

Medications:
– Lisinopril 10 mg daily for hypertension.

Allergies:
No known medication allergies.

Social History:
The patient is a non-smoker and does not consume alcohol. There is no history of illicit drug use. He is married, lives with his spouse, and has two children. He works as an accountant and denies any occupational exposures. He exercises regularly and leads a generally healthy lifestyle.

Family History:
There is no significant family history of neurological diseases or any other significant medical conditions.

Assessment:
Guillain-Barré syndrome (GBS) is a rare autoimmune disorder characterized by progressive muscle weakness and paralysis. It is thought to be triggered by an immune response to an infection or viral illness. GBS usually starts with weakness and tingling sensations in the legs and can progress upward, affecting the arms and respiratory muscles.

The patient’s symptoms of lower limb weakness and tingling, along with the absence of any other significant medical history or symptoms, are consistent with a diagnosis of GBS. However, further investigations, particularly nerve conduction studies, will be necessary to confirm the diagnosis.

Plan:
1. Admit the patient to the neurology department for further evaluation and management.
2. Perform a comprehensive neurological examination to assess the extent and severity of muscle weakness and sensory abnormalities.
3. Order nerve conduction studies to evaluate for peripheral nerve involvement and confirm the diagnosis of GBS.
4. Initiate supportive care, including intravenous immunoglobulin (IVIG) therapy, to reduce the immune response and slow the progression of the disease.
5. Monitor the patient closely for respiratory function, as GBS can lead to respiratory muscle weakness and respiratory failure.
6. Provide physical therapy and rehabilitation to promote recovery and prevent complications such as muscle atrophy and contractures.
7. Involve the patient’s family in discussions about the diagnosis, prognosis, and treatment plan, providing education and emotional support.
8. Arrange for follow-up appointments to monitor the patient’s progress and adjust the treatment plan as necessary.

References:
1. Sejvar JJ, Baughman AL, Wise M, Morgan OW. Population incidence of Guillain-Barré syndrome: a systematic review and meta-analysis. Neuroepidemiology. 2011;36(2):123-133. doi:10.1159/000324710
2. Willison HJ, Jacobs BC, van Doorn PA. Guillain-Barré syndrome. Lancet. 2016;388(10045):717-727. doi:10.1016/S0140-6736(16)00339-1