Question

Create a SOAP Note and determine the injury for the following:

You are the Certified Athletic Trainer overseeing your high school state finals swim meet on a hot
summer day. Due to the level of the competition there is a larger crowd than usual. During the last lap
of the meet tension is higher than ever and you began to hear screams of terror from the crowd. You
run over to the audience to find an elderly man collapsed on all four limbs on the floor. You assess the
situation to see that the man is not bleeding and there is no obvious sign of wound. You have the man
take a seat so you may begin your secondary assessment. Upon asking the patients name you notice he
is sweating profusely and unable to speak clearly. You discover from the man's daughter he is 75 years
of age, has had no previous history of illness and had no mechanism of the injury. The daughter informs
you that he had not enough water earlier this afternoon. When handing the patient, the water bottle
you notice weakness in his right arm. After this moment the patients face began to look abnormal. EMS
is called and the patient is transported.

Answer 1

First of all SOAP note stand for subjects- what the patients telling you objective- what you are gathering assessment- everything you basically did you examines etc and last plan- what am I going to do for the patient what meds does he or she need and do I need to get this patient to a higher level of care but there’s way more in all of these steps I’m just giving a brief example. For this patient having multiple certifications and what not I would be the first responder and be able to treat him his daughter would be giving me the subjective since she was in scene and she knows his medical history and what he had that day. The objective for me would be me gathering some vitals, going off what his daughter said happened looking for those symptoms and side efffects you mentioned my assessment would be doing a physical exam my personal favorite is PMARCHP basically a head to toe exam. Upon completing that my plan would conclude that based on what I see from the outside and what the daughter is telling me is that the patient either had a heat stroke but I’m thinking more of a stroke due to the weakness in the one side of the body and not being able to speak typically a stroke effects one side of the body and based off his age and no medical history I would have him escalated to the next echelon of care cause just because I see his outside symptoms no one can make that call he needs to see a doctor who would do everything all over again and determine if he needs a specialist and where to transfer him. I hope that helped you.

Step-by-step explanation: