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? Purchase the answer to view it
SOAP Format: A Case Study Analysis
Introduction:
The SOAP format is a widely used method for documenting patient cases in healthcare settings. It stands for Subjective, Objective, Assessment, and Plan. This approach provides a structured framework for organizing patient information and formulating treatment plans. In this assignment, we will analyze two videos and write up the scenarios presented in a SOAP format. We will also consider any potential modifications to the existing plan.
Video 1 Analysis:
Subjective:
In the first video, the patient is a middle-aged woman presenting with persistent lower back pain for the past three months. The pain is described as a dull ache that worsens with prolonged sitting or physical activity. She rates the pain as a 7 out of 10 on a pain scale. The patient reports no history of trauma or accidents but mentions occasional numbness and tingling sensations down her legs. She states that the pain is affecting her ability to work and engage in daily activities.
Objective:
The objective findings in the video include the patient’s physical examination and diagnostic tests. The clinician notes tenderness over the lower lumbar region and limited range of motion. Straight leg raise test provokes pain and reproduces radicular symptoms down the right leg. X-ray imaging shows degenerative changes in the lumbar spine, notably disc space narrowing at L4-L5 and L5-S1 levels.
Assessment:
Based on the subjective and objective findings, the assessment indicates a likely diagnosis of lumbar degenerative disc disease with radiculopathy. The patient’s symptoms, such as persistent low back pain, radiating leg pain, and positive findings on physical examination and imaging, support this diagnosis.
Plan:
The current plan involves conservative management initially. The clinician recommends a course of physical therapy to alleviate pain, improve range of motion, and strengthen the supporting muscles. The patient will be educated about posture correction and ergonomics to minimize strain on the lower back. Non-steroidal anti-inflammatory drugs (NSAIDs) are prescribed to control pain and reduce inflammation. The clinician also advises the patient to avoid prolonged sitting and lifting heavy objects.
Modification:
Upon reviewing the plan, there are a few modifications that could be considered. Firstly, the use of adjunctive modalities such as heat therapy or transcutaneous electrical nerve stimulation (TENS) could be beneficial in managing pain and facilitating muscle relaxation. Additionally, considering the patient’s reported numbness and tingling, a trial of oral steroids or epidural steroid injections could be considered to target the inflammation and alleviate radicular symptoms. However, the decision to pursue these interventions should be made in conjunction with appropriate medical consultation and consideration of potential risks and benefits.
Video 2 Analysis:
Subjective:
In the second video, the patient is a middle-aged man with a history of hypertension and type 2 diabetes. He presents with complaints of chest pain and shortness of breath that have been occurring intermittently for the past few weeks. The pain is described as a tightness or pressure-like sensation in the center of the chest, radiating to the left arm. The patient states that the symptoms are precipitated by exertion and relieved by rest. He denies any associated symptoms such as nausea or diaphoresis.
Objective:
The objective findings in the video include the patient’s vital signs, physical examination, and diagnostic tests. The clinician notes that the patient’s blood pressure is elevated, and a systolic murmur is heard on auscultation. The electrocardiogram (ECG) shows ST-segment depression in leads V2 to V6, indicating myocardial ischemia. A subsequent exercise stress test results in chest pain and further ECG changes consistent with myocardial ischemia.
Assessment:
Based on the subjective and objective findings, the assessment points towards stable angina pectoris likely due to underlying coronary artery disease. The patient’s history of hypertension and diabetes, along with the typical chest pain that is exertion-induced and relieved by rest, support this diagnosis.
Plan:
The current plan involves a combination of pharmacological and non-pharmacological interventions. The patient is started on antiplatelet therapy (e.g., aspirin) and a high-intensity statin to reduce the risk of cardiovascular events and manage lipid levels. Lifestyle modifications including regular exercise, a heart-healthy diet, and smoking cessation are recommended. The clinician also schedules the patient for a coronary angiogram to determine the extent and location of any coronary artery narrowing.
Modification:
After reviewing the plan, it may be prudent to consider additional diagnostic tests, such as stress echocardiography or coronary computed tomography angiography, to further assess the extent and severity of the coronary artery disease. These tests could provide additional information about the potential need for coronary revascularization procedures like percutaneous coronary intervention (PCI) or coronary artery bypass grafting (CABG). Additionally, a consultation with a cardiologist could be beneficial to determine the optimal management strategy based on the patient’s comorbidities and individual risk profile.
Conclusion:
In conclusion, the SOAP format provides a systematic and comprehensive approach to documenting patient cases. Analyzing the two videos using this format helped to identify the subjective and objective findings, formulate an assessment, and propose a management plan. The modifications suggested in both cases aimed to optimize treatment outcomes by considering potential additional interventions supported by evidence-based practice.