Question

What would be the proper way to document an assessment from this case study?   

Answer 1

Document of assessment from a case study is called SOAP, Subjective,Objective,Assessment and Plan

SUBJECTIVE

it includes documenting patient's name, and it is the subjective section ,wher we are to record the complaints of the patients in their own language. Try to record accurately and choronological order,the patients complaints. We can quote as the patient narrate if it is any specific symptoms for a particular disease eg:- heaviness in the chest it is specific for myocardial infarction

OBJECTIVE

It includes the recording of findings after clinical examination and record system wise

here we have to record what we see, feel, measure and hear

General appearnce:- record height,weight, calculate BMI,

Vital signs:- Pulse rate, BP, Respiration

fluid balance:- hydration, urine output

Cardiovascular system:-any visible pulsation, heart sounds

Respiratory system: look for wheeze, air entry in all lung fields bilaterlly

Gastrointestinal system:-look for abdominal distension, visible pulsation, dilated veins , bowel sounds

Central nervous system:- any focal defecit, movements and motor power

Laboratory investigations:- blood tests, ECG,Echo,EEG

ASSESSMENT:-

come to a diagnosis

eg: if the patient came with complaints of chest heaviness, on objective findings tachycardia, raised blood pressure, and on ECG there is ST segment changes you can come to a diagnosis of Acute Coronary Disease

PLAN

how we are going to manage the patient

this includes :-

further consultation required if any\

medications

further investigation if needed