Focused SOAP Note Template

Patient Information:

Ms. B, 53-year-old Caucasian female

Subjective

Chief Complaint “Weakness”

History Present Illness: Ms. B is a 53-year-old caucasian female with a history of myotonic dystrophy. She presented to the emergency department (ED) on 2/23/21 with complaints of generalized weakness. Reports more weakness in her left extremities. The patient was seeking physical therapy or rehabilitation. Ms. B was admitted overnight for observation. Overnight she developed shortness of breath (SOB) and confusion. She progressed from a nonrebreather to a BiPAP. She transferred to the intensive Care Unit (ICU). The chest x-ray showed a large left pleural effusion, which left lower lobe pneumonia. Blood Cultures were collected, and she was started on intravenous antibiotics. The patient’s condition continued to decline, and she was ultimately intubated.

 

Location: Generalized

Onset: Known Myotonic dystrophy progressing

Character: weakness progressing and greater on her left side

Associated signs and symptoms: shortness of breath of exertion

Timing: unknown but worsening daily

Exacerbating/relieving factors: resting, and minimal activities

Severity: severe generalized weakness, the patient is unable to care for self

Current Medications:

acidophilus one packet, per G tube once daily

busPIRone 5 mg, per G tube, 2X daily

chlorhexidine 5 ml, mouth/throat 2X daily

enoxaparin 1mg/kg, subcutaneous every 12 hours

ferrous sulfate 300 mg per G tube 2X daily

furosemide 20 mg, intravenous 1X daily

midodrine 5 mg per G tube 2X daily

omeprazole 20 mg per G tube 1X daily

pediatric multivitamin one tablet per G tube 1X daily

polyethylene glycol 17 g per G tube 1X daily

potassium bicarbonate 25 mEq per G tube 2X daily

scopolamine one patch transdermal every 72 hours

sodium chloride 3 ml intravenous, every 12 hours

 

Allergies: Milk- nausea, and vomiting

Past Medical History:  Myotonic dystrophy, current on all recommended immunization except the COVID-19 vaccine, DVT, closed fracture of left tibia and fibula, cellulitis of the lower extremity, generalized weakness, acute respiratory distress, morbid obesity, Anemia, Impaired mobility, and activities of daily living, methylene THF reductase deficiency and homocystinuria, Barrett’s esophagus, GERD

 

Social and Substance History: Ms. B grew up in Little Rock and graduated high school. She is divorced with one special needs son. Both live with her mother. She is a former cigarette smoker. She smoked for two years, stopped in 1986. No other tobacco products. No alcohol use. Current marijuana usage. She is sexually active with male partners and no birth control method. She does not work outside the home. She denies any exercise. She always uses a seat belt. She is disabled and enjoys musicals and theatre. She does not have an advanced directive and names her mother as her healthcare surrogate.

Family History: Brother died two years ago with the same genetic disorder (myotonic dystrophy). Son- moderate developmentally delayed No other family history provided.

Surgical History: cataract removal, cholecystostomy, left tibial fibula fracture repair with hardware, central venous line placement, tracheostomy, gastrostomy tube placement, EGD percutaneous placement.

Mental History: No history of mental illness and no current concerns

Violence History: No history of violence and no current concerns

Reproductive History: Post-menopausal; one son with special needs

 

Review Of System: (On Admission)

GENERAL: Report generalized weakness, worse of the left side

HEENT: Denies any vision or hearing changes.

SKIN: Denies any current skin conditions

CARDIOVASCULAR: Denies chest pain

RESPIRATORY: Denies any shortness of breath

GASTROINTESTINAL: Denies any changes in appetite or eating regime, denies nausea, vomiting, or diarrhea. Denies any abdominal pain or change in bowel pattern

GENITOURINARY: Postmenopausal, denies any urinary changes, burning, frequency, or urgency

NEUROLOGICAL: Denies any headache, numbness, or tingling in the extremities.

MUSCULOSKELETAL: Positive for generalized weakness more significant in the left extremities compared to the right extremities

HEMATOLOGIC: Denies any bleeding or bruising

LYMPHATICS: Reports cellulitis has resolved

ENDOCRINOLOGIC: Denies History of Diabetes or thyroid disease

PSYCHIATRIC: Denies History of depression or anxiety

Objective

GENERAL: The patient is sedated in the ICU on a mechanical ventilator. V/S: Temp 99.0, HR 104, Resp 30, B/P 122/77, POX 96%, HT 5’5, WT 228, BMI 38, morbidly obese

HEENT: Tracheostomy

SKIN: No rash, bruising, or edema

CARDIOVASCULAR: S1 S2 present, regular, rhythm, and tachycardia, no murmur

RESPIRATORY: no wheezing, unlabored on a ventilator

GASTROINTESTINAL: Peg Tube feeding, bowel sounds are active in all four quadrants, soft, large pannus, no mass or enlarged liver or spleen  noted

GENITOURINARY: foley to gravity, yellow clear urine

NEUROLOGICAL: sedated

MUSCULOSKELETAL: no clubbing, cyanosis, known myotonic dystrophy

HEMATOLOGIC: HGB 9.6 to 13.2

ENDOCRINOLOGIC: blood glucose 148

 

Diagnostic results: Ultrasound -RLE DVT, Chest x-ray- LLL pneumonia, Urine Cultures- enterococcus UTI, lab CBC- anemia, blood cultures-sepsis

Assessment

• Myotonic dystrophy- Myotonic dystrophies are multisystemic diseases characterized not only by muscle and heart dysfunction but also by CNS alteration. Myotonic dystrophies (DM1 and DM2) are autosomal dominant multisystemic diseases (Gourdon & Meola, 2017).
• Acute respiratory failure- Respiratory muscle weakness can affect lung function and deprive the body of needed oxygen. Weakness of the diaphragm and other breathing muscles can lead to problems getting enough oxygen (Muscular Dystrophy Association, n.d.)
• Pneumonia- Aspiration pneumonia is common with MD because of recurrent aspiration. They are caused by either impaired swallowing or episodes of gastro-oesophageal reflux. Aspiration occurs from above when food, saliva, or liquids are breathed into the lungs. In contrast, gastro-oesophageal reflux aspiration occurs from below by the reappearance of a bolus of food or stomach content into the pharynx (Lo Mauro & Aliverti, 2016).

 

Plan

• RLE DVT seen on US, on lovenox
• LLL Pneumonia IV antibiotics initiated
• Enterococcus UTI started on ampicillin
• Septic shock possibly, caused by UTI. Sepsis protocol initiated levophen stopped (vasopressor)
• Myotonic dystrophy worsening weakness, Physical Therapy evaluation, and Neurology is following
• Diastolic heart failure- watch volume status and cardiology following
• Anemia- Packed red blood cell transfused, and H&H has improved
• Morbid obesity- diet and exercise when able
• dysphagia- the patient is intubated, and the airway is protected
• Moderated malnutrition- on tube feeding and registered dietician is following
• Palliative Care is following

 

Reflection: This practicum is in palliative care. On several different occasions, my preceptor educated the patient on the need to complete a health care “Living will” patient declined to complete a living will and made her mother her healthcare surrogate. The mother states she would try all aggressive treatment to prevent the patient from dying. The mother says her son died two years ago from the same genetic disorder. The mother stated she “could not take losing another child.” I would not have done anything differently. As a parent, I most likely would have responded in the same way. The patient and mother are both aware of the disease’s long-term effects, and both are willing to learn all medical care to care for the patient at home.

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References

Gourdon, G., & Meola, G. (2017). Myotonic Dystrophies: State of the Art of New

Therapeutic Developments for the CNS. Frontiers in cellular neuroscience, 11,

101. https://doi.org/10.3389/fncel.2017.00101

Lo Mauro, A., & Aliverti, A. (2016). Physiology of respiratory disturbances in muscular

dystrophies. Breathe (Sheffield, England), 12(4), 318–327.

https://doi.org/10.1183/20734735.012716

Muscular Dystrophy Association. (n.d.) Myotonic Dystrophy (DM).

https://www.mda.org/disease/myotonic-dystrophy/signs-and

-symptoms/adult-onset-DM#

ANSWER

 

 

An End-of-Life plan

Based on Ms. B’s health situation, her condition is deteriorating, and based on her family history, she is more likely to fail to survive. This calls for an end-of-life plan, given that she lives with her mother, who is willing to try all aggressive treatment to prevent the patient from dying.  The plan entails assessing the patient by the nurses, where they will then evaluate the family members’ anxiety and, in this case, the patient’s mother and child (NHS, 2018). This is to be followed by establishing a rapport and the difficult situation the family is in.

There will then be a determination of the levels of impairment of perceptual, cognitive, and physical abilities, where the patient is currently weak and unable to function correctly due to her condition.   After all these assessments, there is a need to convince the family members to accept that is happening and be willing to expect any outcome from the patient given her condition (vera, 2019).  The provided information regarding the family problems is vital in that it will help determine solutions and develop a final plan. For this case, it is apparent that the patient’s brother had a  similar condition, and needed up succumbing, which shows the high probability of not making it for the patient.

It will be the nurse’s responsibility to assist the patient and the family in understanding the condition and survival chances.  Information wild helps the family be prepared for anything and also understand the challenges faced by the medics in treating the patient’s condition (Saraiya, Bodnar‐Deren, Leventhal, & Leventhal, 2008). There will finally be a need for facilitating and developing a trusting relationship with the mother since the patient is in no position to communicate due to her illness.

 

 

References

NHS. (2018). End of life care. Retrieved from https://www.nhs.uk/conditions/end-of-life-care/#:~:text=This%20is%20sometimes%20called%20advance,you’re%20still%20able%20to.

Saraiya, B., Bodnar‐Deren, S., Leventhal, E., & Leventhal, H. (2008). End‐of‐life planning and its relevance for patients’ and oncologists’ decisions in choosing cancer therapy. Cancer: . Interdisciplinary International Journal of the American Cancer Society, 113(S12), 3540-3547.

vera, M. (2019). 4 End-of-Life Care (Hospice Care) Nursing Care Plans. Retrieved from https://nurseslabs.com/4-end-of-life-care-hospice-care-nursing-care-plans/