Soap Note.

Soap Note.

Soap Note

The patient encounter is the interaction of a patient with the healthcare providers.  According to Nimmon, L (2016), the patient encounter involves the sharing of knowledge and power with the patient. It consists of the assessment of the condition of the disease, type of attention or care needed to the particular patient, and recording the patient’s information such as age and date of the encounter. An encounter form will be created based on the patient’s history, or if the patient is a new visitor, the form of a new encounter form is created.

Patient encounter

At the start of the week, I had a patient encounter with a patient who was a regular visitor to the hospital.  During the encounter, it was also necessary to select the level of attention the patient needed; those who needed a high attention level of care, and medium attention level of care. Firstly, I checked if the patient had past recorded information at the hospital database, as this would aid in the smooth formulation of an encounter form.  Retrieving the data was also helpful in accessing the patient-important data and past relevant information about the patient illness.

Secondly, the encounter was about the assessment of the patient and the diagnosis of the particular illness. This process involves a presentation of what the patient is feeling, either orally or verbally. Furthermore, I prescribed medication in the encounter form. This was per the assessment of the patient. I also prescribed the patient to have a lab test of blood to ascertain the illness.

Acute care involves the provision of short medical care to patients. The administration of attention is given to the patients immediately after successful surgery or to a patient with an urgent medical condition. We addressed an issue in cardiac failure, which is caused by high blood pressure. This affected the patient’s heart ability to pump blood effectively to the body organs. By checking at the patient record, we were able to ascertain that probably the cardiac failure was due to high blood pressure. The patient had been diagnosed earlier with high blood pressure.

Firstly, we did a cardiac resynchronization therapy, which leads to increased chamber efficiency and increased rate of metabolism, hence lowering the blood pressure. According to Teerlink, J. R (2016), patients admitted with cardiac failure are given a left ventricular ejection of dyspnea and a high concentration level of plasma. Thus, we injected the patient with dyspnea and highly concentrated plasma to lower his blood pressure. We also advised the patient on dietary regulation on the levels of sodium intake.

SOAP NOTE.

Soap note is a document used by medical specialists such as doctors and nurses to ascertain the condition of a patient. It gives an organized form of the patient’s information in a detailed way. The acronym SOAP   means subjective, objective action to implement, and the specialist plan.  It helps in recognition of a patient while proving a course for treatment.

Doctors name:

Date and time in:

Subject

Patient name…                  occupation …                                               age…

The patient has lost appetite, and he experiences high fever during the night and frequent headaches throughout the day. He sickens and vomits regularly — pain in the abdomen and persistent diarrhea.

Objective

Height- 6.2feets, Weight 64 kg.

Lab results: positive CBC test and a positive RDT test.

: Results from the rapid test.

Action

Consume food with high protein concentration and highly leafy vegetables

Use of a mosquito repellant when traveling to areas with high mosquito infestation.

Plan.

I recommend a dose of Artesunate and antifolate- pyrimethamine for malaria treatment.

Guidelines

The programs developed a focus on most vulnerable people with low immunity. Treatment for these vulnerable people is administered within an average of 24 to 48 hours of diagnosis. Furthermore, maintenance of a full dosage to malaria campaign drugs should be promoted, and malaria patients should adhere to a full dosage. Treatment for malaria is administered with two effective antimalarial medicine to prevent its occurrence and resistance.  Moreover, it is appropriate to achieve weight-based criteria for malaria dosing as this maximizes the probability of cure and prevention of transmission.

Recommendation

Use of sulfadoxine­-pyrimethamine to prevent malaria in pregnant mothers is essential. Besides, the treatment of infants at birth with sulfadoxine-pyrimethamine to prevent malaria attack in a newborn is equally crucial. Conducting regular screening and provision of treatment to pregnant women is recommendable to fight against malaria. Administration of the appropriate drug to treat malaria to both children and grown-up is another strategy that is employed to fight against malaria. Moreover, it is essential to refer to cases of severe malaria to a better facility to get better services and experts that are more experienced. However, for a risk group, it is essential to administer chemoprevention.

Pathophysiologic of Malaria

Pathophysiologic is the study of how a particular disease causes physical and biological variation in the body of a patient after infection with the diseases. Severe malaria is associated with a psychotic disorder, memory loss, and general aggressiveness. Moreover, science has proven that cerebral malaria is associated with neurological disability, which is associated with macro-vascular impedance and tissue alteration after cytokine cascade (Goodier, 2020).

Furthermore, to young persons, malaria may cause a derivation in brain development due to neurophysiological disability, which causes hypoxia and tissue inflammation. However, these are long term and biological effects of severe malaria development. Short-term pathophysiologic effects may include high fever at nights: vomiting and nausea, and abdominal pains at the medium stage of infection. General body weakness, high rate of sweat. Hypoglycemia, especially in pregnant mothers, may be characterized by cardiovascular impairment. The level of malaria effect on the patient’s body influences the clinical decision. This includes the stage of malaria infection, incubation, severe or middle stage malaria. The type of infection, which include P. Vivax and P. Ovale infections, may also influence the decision.  Pregnant women may also influence the clinical decision on consideration of malaria may cause pregnancy complications. People with low immunity may also affect the clinical decision as they are given first consideration.

References.

Nimmon, L., & Stenfors-Hayes, T. (2016). The “Handling” of power in the physician-patient

Encounter: perceptions of experienced physicians. BMC medical education, 16(1),

Teerlink, J. R., Felker, G. M., McMurray, J. J., Ponikowski, P., Metra, M., Filippatos, G. S., … & Lei, L. (2016). Acute treatment with omecamtiv mecarbil to increase contractility in acute heart

Failure: the ATOMIC-AHF study. Journal of the American College of Cardiology, 67(12), 1444-1455.

Goodier, M. R., Wolf, A. S., & Riley, E. M. (2020). Differentiation and adaptation of natural

killer cells for anti‐malarial immunity. Immunological reviews.