The SOAP Method

Lymphedema is a condition that occurs because lymph nodes are removed and/or are damaged, thus creating a blockage in the lymph system, which operates our immune responses. (Mayo Clinic 2014) The blockage prevents the drainage of lymph fluid and its buildup causes swelling. The swelling is visible and palpable. The pain assessed by the affected female was described as a feeling of heaviness and tightness, a throbbing ache and overall discomfort. She claims there is also pain felt in the skin with a hardening and thickening that limits her range of motion. The pain worsened over the course of a few months after radiation, which is common and requires ongoing occupational therapy to manage. The pain occurs daily and with overuse, swelling increases, as does the pain. It is recommended that certain activities like strenuous activities, lifting, and physical labor irritates the situation. The interviewee compared the pain to a backed up tub that fills when the drain is clogged and it gets sluggish and then there is a buildup that requires a clearing/flushing for fluid to

Heather is a 48 year old patient who was referred to my group by her oncologist in bowling green. She had chronic _______and now has a 4.0cm lesion with __________but no lymph node involvement, luckily. Aside from being a heavy tobacco smoker and of heavy weight, she is otherwise healthy. Patient will have surgical resection this week.

Evaluation and management services have seven components to define the service they include: history, examination, medical decision making, counseling of care, nature of present problem, and time. When selecting the level of E/M service the key components are history, examination and medical decision-making; unless the visits are mainly for counseling or coordination of care, then time will be the key component for selecting the level of service. The level of E/M service is based on four types of history ( problem focused, expanded problem focused, detailed and comprehensive). Each type will include some or all of the chief complainant(CC) describing the symptoms, problem, or condition, reason for the visit. History of present illness (HPI) describes the location, severity, duration, timing, modifying factors and associated signs and symptoms. Review of systems (ROS) is an inventory of the various body systems that may be related to the patient HPI through questioning. Past, family, or social

A-Analysis: Conclusion staff comes to, based on hte interpretation of the subjective and objective data about hte patient's problems

The patient was a 57-year-old married man living on disability insurance. He was admitted to the hospital with a chief complaint of sub sternal pressure-like discomfort, and pain radiating to the back and upper left extremity, which had started four to five hours before intake. The pain

Assess for pain given the rate of metastasize cancer could affect many organ and become

Based on the medical report dated 05/ 2616, the patient complains of headaches and stabbing upper back and shoulder blade pain radiating to her lower back. She also has neck pain, described as burning. Pain is rated as 8/10 to the neck, lower and middle back and head. When she is on medications, her neck and mid/low back pain and her headaches reduced to a 4/10. She gets anxiety and it is related to her rapid heart rate, s which makes it feel she is in pain and this

Objective data is what the nurse or doctor can measure or assess be it through: sight, sound, smell or touch (hopefully not taste), objective data collection can be repeated and verified by other health care workers. Obtaining objective data is the most accurate method for determining what is wrong with a patient and how to form a plan of care for them. Subjective data is what the patent personally experiences and tells or indicates to the nurse, while not standardized and differs between people it can indicate problem areas holistically for evaluation including physical, mental, social, emotional and spiritual difficulties. Mr Jones’s objective data assessment would include: heart rate, blood pressure, respiratory rate, temperature, fluid balance, O2 stats, BLG, ECG, functionality, breathing sounds and other observations. These observations can paint a clear picture of Mr Jones’s current condition and guide his treatment and recovery. Subjective data for Mr Jones would include: pain (location, type of pain, duration of pain), discomfort, dizziness, anxiety and any other abnormalities he is personally experiencing.

Based on the medical report dated 05/26/16, the patient reports neck pain which places limits her physical activities. Pain is elevated with sitting, standing, lifting, and ambulating. She has noticed stiffness in the mornings and difficulty sleeping due to the nature of the pain. She reports difficulty with bending her neck, side bending, twisting, lifting and carrying. Patient has received multiple treatments including medication prednisone, Neurontin, and Mobic along with physical therapy, however the pain still persists.

At the beginning of your appointment, a nurse may ask you why you are visiting the doctor’s office. A health professional will document information that may include personal information, any health complaints that you may have, and your symptoms. You may be asked about your level of pain, discomfort, or any medical history. These items are considered subjective because they cannot really be measured and may be different for anyone who is experiencing

This essay is a cases study on Patient M, firstly I will discuss the client’s diagnosis and the pathophysiology. Secondly I will discuss the patient’s history both past and present including the presenting complaint, medical, surgical history and social history. Thirdly I will discuss the clinical examinations, diagnostic tests and their findings. From this I will

The member is a 46-year-old gravida 1, para 1, female. She complained of a left breast lump and moderate to severe persistent pain that refers to the left axillary area. There was a report of a recent mammography from 08/29/2015 that was normal. She also had a left shoulder ultrasound and left shoulder MRI with finding of non-specific left axillary lymph nodes. A physical examination was performed with an area of tenderness noted in the member’s left breast (but no mass) and enlarged tender axillary nodes on the left. On 12/29/2015, she underwent a bilateral breast MRI. The results were negative with no findings of

Cancer is one of the most dangerous diseases that have arisen in the recent decade on a faster note. The development of cancer is so fast that it is very difficult to detect in the initial stages. The main issue with some cancer patients is that there are no symptoms in the initial stages and they live their normal life as it is, and the pain starts after the cancerous cells have spread to the lymph nodes or bones or sometimes other parts of the body.

Patient was seen in-house found to have a personal history of lymphoma. The patient had a prior PET scan, which showed activity within the left axilla. The operative indications regarding this were discussed with the patient and an informed consent was signed and placed in the chart. An operative date was set at 11/02/2017 by Dr. Shane Hodge being the surgeon attending,

In this situation, the practical nurse is required to do a physical examination on a 68 years old female with chief complaint of mild pain in her lower chest and