Practicum Experience – Comprehensive SOAP Note #3 nurs6531
After completing this week’s Practicum Experience, review the Comprehensive SOAP Note Exemplar and Template in this week’s Resources, and reflect on a patient who presented with musculoskeletal disorders or pain. Describe the patient’s personal and medical history, drug therapy and treatments, and follow-up care. Practicum Experience – Comprehensive SOAP Note #3 nurs6531
All SOAP notes must be signed and each page must be initialed by your preceptor. When you submit your SOAP Notes, you should include the complete SOAP Note as a Word document and pdf/images of each page that is initialed and signed by your preceptor. You must submit your SOAP Notes using SAFE ASSIGN.
Please Note: Electronic signatures are not accepted. If both files are not received by the due date, faculty will deduct points per the Walden Late Policies.
By Day 7 of Week 8
This Comprehensive SOAP Note #3 is due. You will submit two files for the Week 8 Comprehensive SOAP Note #3, including a Word document and pdf/images of each page that is initialed and signed by your preceptor by Day 7 of Week 6.
Expert Answer and Explanation
Comprehensive Soap Note
Patient Initials: ___AA____ Age: ___27 years____ Gender: _____Male__
Subjective Data
Chief Complaint:
“My back is paining a lot.”
History of Present Illness:
AA is a 27 African American male who visited a healthcare facility complaining of back pain. The patient noted that he had been feeling the pain for the last four days. The patient noted that he started feeling lower back pain after falling in the bathroom six weeks ago, but the pain became severe four days ago. He reported that he tried taking over-the-counter Tylenol, but the pain has not reduced. The pain can be scaled as 7/10.
Medication: OTC Tylenol.
Allergies: No allergies.
Past Medical History: He has never been hospitalized. He was treated for pneumonia one year ago.
Past Surgical History: No major surgery.
OB/GYN History: N/A
Personal/Social History: He often drinks alcohol every weekend but does not smoke Immunizations: He received pneumonia vaccine 1 year ago.
Family History: His dad died of a car accident, and his mother died of a heart attack. Review of Systems
General: The patient has fatigue, fever, weight loss, diarrhea, and loss of appetite.
The patient has a fever, fatigue, diarrhea, weight loss, and reduced appetite
HEENT: Healthy head, eyes, ears, nose, and throat.
Musculoskeletal: Back and rectal pain.
Gastrointestinal: Cannot defecate though has the urge to defecate.
Hematologic: Reports bleeding ulcers.
Objective Data
Physical Exam: The patient was seen limping during the physical examination, and his lower back was swollen and tender. His eyes were also swollen.
Vitals: BP 127/82, Temp 39.2 degrees centigrade, Wt 74, Ht 189cm, RR 20, Hr 76.
Assessment
- Inflammatory Bowel Disease- This disease is the primary diagnosis for this case. IBD is an infection that causes pain in the lower abdomen (Colombel et al., 2017). This disease is the primary diagnosis because the patient reports most of its symptoms
- Colon Cancer-Colon cancer is the cancer that affects the colon. It has been included in diagnosis because it causes abdominal pain.
- Bowel Obstruction-This condition has been included in the diagnosis because it also causes abdominal pain by blocking digestion wastes in the intestines.
Plan
Treatment Plan
Blood test, stool test, and X-ray were ordered and the patient found to have IBD. The disease can be treated using three types of drugs, including painkillers, anti-inflammatory medications, and antibiotics. The patient should be recommended Dipentum 1.0 g/day twice a day for ten days (Sakur et al., 2019). Dipentum is a medication used to treat inflammation. To relieve his pain, the nurse should recommend diclofenac sodium Voltaren 18 mg orally thrice a day for four days (Rosen et al., 2017). The patient should be recommended Cipro 500 mg orally twice a day from 4 weeks to fight infection.
Follow-Up Care
The first follow up care for this patient is a checkup (Brandenbarg et al., 2017). The patient should be told to visit the hospital two weeks after being discharged so that the nurse can check and see how the patient is fairing. The nurse can also implement follow up care by calling the patient often to find out how he is doing.
Reflection
From this soap note, I have leaned that nurses should conduct proper diagnosis on their patients before recommending any medication. I have also learned that nurses should plan follow-up care programs to ensure that patients respond well to medication.
References
Brandenbarg, D., Berendsen, A. J., & de Bock, G. H. (2017). Patients’ expectations and preferences regarding cancer follow-up care. Maturitas, 105, 58-63. https://doi.org/10.1016/j.maturitas.2017.07.001
Colombel, J. F., Sands, B. E., Rutgeerts, P., Sandborn, W., Danese, S., D’Haens, G., … & Parikh, A. (2017). The safety of vedolizumab for ulcerative colitis and Crohn’s disease. Gut, 66(5), 839-851. http://dx.doi.org/10.1136/gutjnl-2015-311079
Rosen, M. J., Karns, R., Vallance, J. E., Bezold, R., Waddell, A., Collins, M. H., … & Baker, S. S. (2017). Mucosal expression of type 2 and type 17 immune response genes distinguishes ulcerative colitis from colon-only Crohn’s disease in treatment-naive pediatric patients. Gastroenterology, 152(6), 1345-1357. https://doi.org/10.1053/j.gastro.2017.01.016
Sakur, A. A., Dabbeet, H. A., & Noureldin, I. (2019). Novel Drug Selective Sensors for Simultaneous Potentiometric Determination of both Ciprofloxacin and Metronidazole in Pure form and Pharmaceutical Formulations. Research Journal of Pharmacy and Technology, 12(7), 3377-3384. DOI : 10.5958/0974-360X.2019.00570.5
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