MOA LYUDMILA GCC

Student Learning outcomes

The SOAP note helps guide healthcare workers use their clinical reasoning to  assess, diagnose, and treat a patient based on the information provided  by them. SOAP notes are an essential piece of information about the  health status of the patient as well as a communication document between  health professionals.

Describe terms within the body system Define organs and their functionality Discussthe application and uses of terms in patient care  

This is a case study of Mr. Jones Murray –

The information collected is unorganized and redundant,  you may also need to research some terms to understand the medical  report fully.

Once you read, review, and analyze the information on  this page – download the SOAP Chart from the module and complete the  chart using the information from this case study –

Do not improvise or fabricate – all information on the SOAP chart should be authentic and extracted from this Medical Report.

This is a great opportunity for you all to review the  disease /conditions this patient has and conduct research that will make  you’re learning a memorable experience.

The objectiveof this projectis  to learn Medical Terminology Terms, Definitions, and applications  within the context of body Systems and their uses in patient care  services by using the SOAP chart ( progress note )

The objective is not to learn to document a patient chart as a physician or any other provider would.

About the Patient

Mr. Jones Murray reports a four-month history of pain in his low back  and recently the pain has moved into his left hip. He states this pain  is different from his previous low back pain; it is lower into his hip  and this is the first time that he has experienced hip pain. His chief  complaint is that when he comes home from work he is too tired to go  fishing or work in his wood shop. He states his doctor instructed him on  dieting and exercise to lose weight and decrease his HTN and  cholesterol, but he states he just hasn’t had the energy to exercise or  perform his usual hobbies. However, he has lost some weight even though  he’s not sure how much. Pt reports the pain wakes him up at night and  can’t seem to get comfortable and sitting for long periods at work  bothers him. He says he recently started doing some of the stretches and  light exercises that were given to him by his last therapist; they  helped a little at first but don’t seem to be making much of a  difference.

Patient Characteristics

Demographic Information: Mr. Jones Murray reports is a 61-year-old Caucasian male.

He has worked as an electrical engineer for 30 years.

Medical diagnosis: Referred from primary care physician to therapy  for low back pain (LBP) due to a history of disc herniation. No recent  imaging. MRI from 5 years ago.

Co-morbidities: HTN, BMI = 27,

Hyperlipidemia

Previous Physical Therapy: Mr. Jones Murray reports has received  prior physical therapy for disc herniation at L4-L5 five years ago.

Patient’s Past Medical History:  Patient reports HTN and high  cholesterol both managed medically.  The patient was hospitalized 10  years ago for infectious mononucleosis, and he reports his mother  passing away from breast CA 10 years ago. The patient reports no other  significant past medical history (liver, lungs, DM, kidneys), and he  does not smoke and rarely drinks alcohol socially because he notices  that drinking makes his pain worse.  Medications: Lisinopril, Crestor, and Aleve (prn)Patient Goals: His primary goal is to decrease his pain and increase  his stamina so that he can return to fishing and working in his  woodshop. Self Report Outcome Measures: Numeric Pain Rating (0-10) is 4 at best and 5 at worst and the pain is constantPhysical Performance Measure: 2-minute walk test, RPE: 16 (distance 125 meters; cardiovascular response WNL, decreased distance likely due to fatigue and need for rest breaks)

ROM: Lumbar ROM 75% of normal, no increase in pain with movement;  Hip ROM 75% of normal, no increase in pain with movement. All other ROM  measurements are within functional limits, with no pain.

Reflexes: +2 for L3/4, L5, and S1

Sensation: Normal

MMT: 4+/5 on LE general exam

Palpation: Hip pain not reproduced with palpation, pain over the  center of sacrum present with palpation, positive Castell’s percussion

Special Tests: + Slump Test, SLR negative bilaterally

Mr.  Jones Murray returned to his PCP. After further medical  screening and testing, he was diagnosed as having Hodgkin’s lymphoma  with metastasis to the lumbar spine area (L5-S1). The patient began  chemotherapy and radiation treatment after having surgery to remove  pelvic malignant lymph nodes. He continued physical therapy per PCP  order to increase cardiovascular/pulmonary health, improve strength and  flexibility, improve lymphedema and reduce fatigue and symptoms produced  from cancer and treatments.

The Patient Health Questionnaire (PHQ-9) was administered to assess  the quality of life/risk of depression once the patient was diagnosed  with CA. Mr. Hodgkin’s initial score was 14 indicating moderate  depressive symptoms. At discharge, his score was 9 indicating he had  moved from moderate depressive symptoms to mild depressive symptoms. The  patient reported that therapy gave him something to do, helped him feel  better throughout his CA treatment, and increased his quality of life.

At discharge, the patient’s 2 minutes walk distance had increased  and his RPE during the test had decreased to 12, and the patient’s pain  in his low back and hip had decreased. He did experience other side  effects from the chemotherapy and radiation treatment, but these were  non-PT related.

   

Hodgkin’s Lymphoma

Hodgkin’s Lymphoma, also known as Hodgkin’s disease, is a “chronic,  progressive, neoplastic disorder of lymphatic tissue characterized by  the painless enlargement of lymph nodes with progression to extra  lymphatic sites such as the spleen and liver.” It  may also metastasize to bone marrow and other organs. The sites  initially affected are the lymph glands in the neck or groin, usually on  one side.

Watch the Video – as additional resources – Conversations With History: The Story of Hodgkin’s Disease

Link

Links to an external site.