What details did the patient provide regarding his or her personal and medical history?

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In addition to Journal Entries, SOAP Note submissions are a way to reflect on your Practicum Experiences and connect these experiences to your classroom experience. SOAP Notes, such as the ones required in this course, are often used in clinical settings to document patient care. Please refer to the Seidel, et. al. book excerpt and the Gagan article located in this week’s Learning Resources for guidance on writing SOAP Notes.
After completing this week’s Practicum Experience, select a patient that you examined during the last 3 weeks. With this patient in mind, address the following in a SOAP Note:
Subjective: What details did the patient provide regarding his or her personal and medical history?
Objective: What observations did you make during the physical assessment?
Assessment: What were your differential diagnoses? Provide a minimum of three possible diagnoses. List them from highest priority to lowest priority. What was your primary diagnosis and why?
Plan: What was your plan for diagnostics and primary diagnosis? What was your plan for treatment and management including alternative therapies?
Reflection notes: What would you do differently in a similar patient evaluation?

This soap note must be on an Hypertension

Case Study: Assessment PAIN5002: Introduction to Pain Management

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Case Study: Mr Jones

Frank Jones is a 48 year old man presenting with low back and left leg pain.

History

Mr Jone was working as a motor mechanic when lifting a heavy piece of machinery

weighing 35 kg (77 lb) on 5 March 2002. He felt something “give” and had

immediate onset of pain in the low back. He was seen by his local doctor and given

antinflammatory medications and told to take 3 days off work. There was no

neurological deficit and X rays of his lumbar spine failed to find any abnormality.

He requested several more days off work and then returned to work one week after

the injury. Any lifting caused an increase in his pain and after consultation with his

local doctor he was placed on light duties. He returned to work and was given office

duties but his boss made it clear that he was not welcome at work if he could not

return to what he was doing before. He was very dissatisfied doing paperwork.

Eight weeks later his pain had largely resolved and he was cleared by his local

doctor and allowed to return to normal duties. Three months later when he bent over

to pick up his tool box he experienced pain in his back and a shooting pain down his

left leg.

He returned to the local doctor who requested a CT scan. This showed a left

posterolateral L4/5 disc protrusion that was impinging on the left L5 nerve root.

He was refered to an orthopaedic surgeon who advised an L4/5 discectomy.

Following surgery, he had good relief of the leg pain although not the back pain and

despite attempts to return to work found it impossible to carry on. He was dismissed

from his job at the mechanical workshop six months later.

He now spends much of his time at home and twelve months following surgery

began to experience constant burning pain in the left leg below the knee. He now

has continuing pain in the low back and left leg.

Mr Frank Jones – Case Study: Assessment PAIN5002: Introduction to Pain Management

© University of Sydney

All rights reserved

Previous intervention

ƒ Physiotherapy (prior to surgery)

ƒ Dec 2002 – Surgery – L4/5 discectomy

Pain

Low back

ƒ Constant aching pain with intermittent stabbing pain with activities

ƒ Worse when sitting or standing for long periods, bending, lifting

ƒ Relieved by lying down, changing position, heat

Left leg

ƒ Constant burning pain particularly over outside of left lower leg and top of left

foot

ƒ Worse at the end of the day

ƒ No relieving factors although better when distracted

ƒ Pins and needles down outside of left leg to foot, numbness over top of foot

ƒ Leg gives way from time to time

ƒ No change in bladder or bowel function

Medications

Current

ƒ oxycodone 5 mg 10-12/day – some relief

ƒ sodium valproate 800 mg/day – not sure if helping

ƒ temazepam 1-2 most nights

Previous

ƒ tramadol, amitriptyline (25 mg nocte) – both gave side effects

Medical history

ƒ Hypertensive – on medication

ƒ Weight gain 15 kgs over last 2 years

Psychosocial history

ƒ Married three children 26, 24, 22 – youngest still at home

ƒ Motor mechanic until discharged from last position, seven years in last

position

ƒ Doesn’t smoke – ceased 10 years ago

ƒ Alcohol – 6-8 cans beer on weekends

ƒ Sleep – better with temazepam  but still woken by pain

Did the victim die from a contact shot that pierced her femoral artery or is it possible the victim was shot from a distance and the black markings are the ring of dirt? Explain your answer.

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Each essay response is to be a minimum of 3 to 4 fully developed paragraphs. Rewriting the essay question is not considered a part of your response. Direct quotes are not to be used in test answers. 

Answers are to be consistent with the college level. The essays shall be written in APA format and include in text citations to credit your sources.

Question 1 of 520.0 Points

As an investigator you have been tasked with solving a hit and run homicide case involving a pedestrian and unknown vehicle. Explain what wounds you may expect to see and how these injuries may help reconstruct the crime.

.

Question 2 of 520.0 Points

One of the biggest challenges to medical examiners today is determining whether an infant died of Sudden Infant Death Syndrome (SIDS) or whether foul play was involved. Discuss the research behind SIDS and what evidence assists the medical examiner in concluding a death was the result of SIDS. Summarize the protocol an investigator should use at a crime scene when investigating a possible SIDS death.

Question 3 of 520.0 Points

Define carboxyhemoglobin and explain its relationship to the MGM Grand Hotel in Las Vegas.

Question 4 of 520.0 Points

Two children were playing hide and seek with friends. With the assistance of another friend, the two children were lowered down into an abandoned well. The well was approximately 15 feet deep. After two days of searching, a police officer located the two missing children deceased inside the well. Neither child had any signs of injury and did not die as a result of exposure, starvation, or dehydration.

Explain your rationale using the assigned readings as well as and external research.

Question 5 of 520.0 Points

A woman sunbathing at the beach in a bikini is found dead of a gunshot wound to the upper right thigh. Black markings can be seen surrounding the entrance wound.

Did the victim die from a contact shot that pierced her femoral artery or is it possible the victim was shot from a distance and the black markings are the ring of dirt? Explain your answer.

What are the implications of using these resources in the healthcare industry? What are the implications for the consumer?

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Research two to three electronic healthcare resources; these could be websites, mobile applications, or multimedia resources used by healthcare consumers for their medical needs.

Write a 350- to 700-word summary discussing the following based on your research:

  • Describe the websites, applications, or multimedia resources.
  • How do healthcare providers use these resources to enhance their products and services?
  • What are the implications of using these resources in the healthcare industry? What are the implications for the consumer?

Cite any outside sources. For additional information on how to properly cite your sources check out the Reference and Citation Generator resource in the Center for Writing Excellence.