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 Discuss the 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 objective of this project is 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.
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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 constant
- Physical 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 LymphomaHodgkin’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
