Question

Protected View - Saved to this PC- O Search Mailings Review View Help Acrobat Jnless you need to edit, it's safer to stay in Protected View. Enable Editing SOAP Note #3 Part 1: Complete a SOAP note using the prompt below. The SOAP may be hand- written (legibly) or typed. Please submit your draft to Forums by Friday at 11:59 PM. Prompt: Sydney Smith, a 6'4", 21-year old female collegiate basketball player sustained a severe strain to her right anterior deltoid muscle during practice yesterday. She has no prior history of injury to this muscle. Observation and palpation revealed immediate local swelling and significant point tenderness. The patient described her pain level as a "7" on a 10-point scale. There is palpable 1 cm depression present in the body of the muscle. While standing, starting from anatomical position, she had only 65 degrees of active glenohumeral abduction range of motion in the involved shoulder. While seated with her right shoulder in anatomical position, Sydney had 96 degrees of active shoulder flexion range of motion. The patient was unable to perform any active horizontal flexion of her right shoulder due to pain. Left glenohumeral joint active range of motion was within normal limits. Manual muscle testing revealed grade 2 glenohumeral flexion and abduction strength, and grade 1 glenohumeral horizontal flexion strength on the right, while grade 5 strength for shoulder flexion, abduction and horizontal flexion was noted on the left. She was given a sling to immobilize the dominant arm. The patient was advised to rest, ice, elevate and compress the injured area with a 6" elastic bandage throughout the day. The team physician was consulted, and he phoned in a prescription for Sydney at the Student Health Center for Tylenol #3, with instructions to take 2 tablets every 4 hours for pain, if needed. She was instructed to return the following morning at 8:00 am for examination by the team physician.

Answer 1

SOAP note:

It is the Acronym for Subjective, objective, Assessment and Plan. It is a documentation format used by Healthcare Providers and describes in brief the condition of the patient and the situation.  

S- Subjective

O- Objective

A- Assessment

P- Plan

SOAP note:

Date: 0-/ 0-/ 2020

S - Patient said that she got a severe sprain on her right hand (anterior deltoid muscle) while playing the basket ball the last day

Patient said her pain level was 7 on a 10 point scale.

O - Local swelling and redness found on Observation and palpation

- 1 c.m palpable depression on body of the muscle

- Glenohumeral abduction ROM 65 degree , on affected side, while standing ans starting from anatomical position.

- ROM 96 degree on shoulder flexion of active side, while sitting.

- Manual muscle testing: Left side

glenohumerral flexion and Abduction strength- Grade 2

Glenohumeral horizontal flexion - Grade 2

Left side:

Shoulder flexion, abduction, horizontal flexion: Grde 5

A- Unable to perform active horizontal flexions with right shoulder due to pain

- ROM impaired on Right shoulder

- Normal ROM on left glenohumoral joint

P - Schedule the appointment with team physician on next day morning 8 am

- Instruct the client to immobilize the affected arm with a sling

- Suggest for rest , ice , elevate and compress the injure area with 6" elastic bandage throughout the day

- Instruct the client to taje two tablets ot Tylenol every 4 hour four hours of pain