SOAP Presentations - 2 Examples — Transcript

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1. 0:01hello it's Eric from strong medicine
2. 0:03today in this series on notes and
3. 0:05presentations I'll be giving two
4. 0:07demonstrations of a classic soap
5. 0:10presentation these are the presentations
6. 0:12that medical and AP students and interns
7. 0:16frequently give to their teams while on
8. 0:18the hospital WS if you haven't already
9. 0:20watched it I recommend first viewing my
10. 0:23video on the format and content of soap
11. 0:26presentations while nearly all services
12. 0:29in American hosit hital use the general
13. 0:31soap format for presentations there are
14. 0:34modest differences in length and content
15. 0:37between different institutions and
16. 0:39different Specialties these
17. 0:41presentations will model what would be
18. 0:43expected on a typical internal medicine
19. 0:47or IM Specialty Service however the
20. 0:50general principles will still apply to
21. 0:53Surgical and pediatric
22. 0:55Specialties lastly for those viewers who
23. 0:57have already seen my two h&p
24. 0:59demonstration
25. 1:00you'll note that these will be the same
26. 1:02patient cases as those one of acute
27. 1:05heart failure and another of sepsis but
28. 1:08as they would be presented on Hospital
29. 1:10day number three after the patients
30. 1:12conditions have changed following 2 days
31. 1:15on
32. 1:21treatment Miss Harris is a 76 year-old
33. 1:24woman with hypertension and a prior Mi
34. 1:26who presented two days ago with acute
35. 1:28decompensated heart failure in the
36. 1:30setting of new onset a fib with
37. 1:33rvr overnight the night team was paged
38. 1:36by nursing due to new onset confusion
39. 1:38and modest agitation the covering
40. 1:41resident assessed the patient at the
41. 1:42bedside uh and felt that she was
42. 1:44experiencing mild Hospital acquired
43. 1:46delirium vitals and exam were
44. 1:48unremarkable aside from her AP fibs
45. 1:51ventricular rates reaching back up to
46. 1:52the 120s the resident opted to hold off
47. 1:55all Labs because of good of uh good
48. 1:57yurine output lack of infection signs
49. 2:01and because the patient's agitation
50. 2:02improved with
51. 2:04redirection this morning subjectively
52. 2:07she reported little memory of the events
53. 2:08of last night she's been feeling less
54. 2:10dmia this morning uh but is not yet back
55. 2:13to her Baseline uh she has no chest pain
56. 2:15palpitations or lightheadedness she had
57. 2:18a good appetite for her breakfast uh
58. 2:20which had not yet been
59. 2:21delivered uh on
60. 2:23exam regarding her exam uh her Vital
61. 2:26Signs uh she's remains a febrile her
62. 2:29heart rates were 110s to 120s during her
63. 2:31Delirious episode as mentioned but
64. 2:33otherwise have been 80s to 100s with
65. 2:36blood pressure 100s to 12s over 60s to
66. 2:3870s respiratory rate 18 to 22 O2 sat of
67. 2:4293 to 97% and eyes and nose were 1.8 in
68. 2:46and 3.2 out for a net 1.4 L negative
69. 2:50mental status appears back to her
70. 2:52Baseline and she was oriented to four
71. 2:54out of four lungs had mild bibas
72. 2:56crackles that are improved compared to
73. 2:58yesterday Ry remains irregularly
74. 3:00irregular with a jvp that is now normal
75. 3:03for the first time this admission repeat
76. 3:06Pocus was deferred due to limited time
77. 3:09mild symmetric lower extremity edema to
78. 3:11the upper shins is
79. 3:13unchanged CBC and BNP were under
80. 3:15remarkable aside from a potassium of 3.2
81. 3:18which was orally
82. 3:19repleted um Telemetry over the past 24
83. 3:22hours uh shows consistent apib with uh
84. 3:26five episodes of nsvt the longest of
85. 3:29which was eight
86. 3:31beats so in summary Miss Harris is a
87. 3:3376-year-old woman with hypertension and
88. 3:35a prior Mi presenting with acute
89. 3:37decompensate heart failure with a new EF
90. 3:40of 30 to 40% hypothesized to be
91. 3:43secondary to Taco cardia induced
92. 3:45cardiomyopathy she is hemodynamically
93. 3:47improved with diuresis and weight
94. 3:49control but now with an episode of
95. 3:51Hospital acquired delirium
96. 3:53overnight problem number one heart
97. 3:55failure given her improving symptoms
98. 3:58improving O2 sat and normalized jvp I
99. 4:01think we are nearing emia diagnostically
100. 4:04Cardiology wants to hold off on
101. 4:06additional esmia workup for now and to
102. 4:08follow up as an outpatient to discuss
103. 4:10whether or not to pursue testing after
104. 4:12recovery from this admission
105. 4:14therapeutically for diuresis we will
106. 4:16continue L 6 20 migs IV bid for today
107. 4:20with a goal of another 1 to 2 L negative
108. 4:22and tentatively plann on switching her
109. 4:24to oral lasic with tomorrow's am dose
110. 4:27for afterload reduction she remains on
111. 4:29her patient l Cil and mapine at the
112. 4:32moment but we anticipate transitioning
113. 4:34her to entresto prior to discharge we
114. 4:37would also like to start imp paglin
115. 4:40today uh problem two her atrial
116. 4:43fibrillation after tolerating an esmo
117. 4:45drip for the first 24 hours in the
118. 4:47emission she's now cautiously remaining
119. 4:49on 12.5 mg q6 of mopolo tartrate with a
120. 4:54heart rate goal of less than 100 to 110
121. 4:57Cardiology plans to proceed with a te
122. 5:00and likely DC cardi version once she's
123. 5:02uvalic possibly as early as tomorrow
124. 5:05afternoon if cardiov version is
125. 5:07successful I anticipate am odone to
126. 5:09maintain sinus rhythm but we'll defer to
127. 5:11cards on that uh she also remains on a
128. 5:13pixan for
129. 5:15anti-coagulation problem three is her
130. 5:17delirium uh which appears resolved for
131. 5:19now with non-pharmacological
132. 5:21interventions given its resolution and
133. 5:23her reassuring exam and Labs from this
134. 5:25morning additional workup is not
135. 5:27indicated at this time nursing requested
136. 5:30in order for PRN quene but I'm holding
137. 5:33off on that because if the delirium were
138. 5:35to recur tonight I actually would want
139. 5:37the patient reassessed and not just
140. 5:39sedate it using appearing order that's
141. 5:41already
142. 5:42there problem four hypertension uh as
143. 5:45already mentioned she's currently on L
144. 5:47April mapine emop though this regimen
145. 5:51will likely be changed prior to
146. 5:54DC uh problem five her CAD continuing
147. 5:58aspirin and atorvastatin work up for
148. 6:00ongoing esea deferred as previously
149. 6:03mentioned finally is dispo I'm hoping
150. 6:06Miss Harris will be able to DC back to
151. 6:08her home in 2 to three days once youal
152. 6:11liic and in scius Rhythm provided that
153. 6:13she's cleared by PT and OT and her
154. 6:16family can increase the level of inhome
155. 6:18support social work and case management
156. 6:21are currently working with them on this
157. 6:30Miss White is a 38-year-old woman with
158. 6:32no relevant chronic medical problems who
159. 6:34presented two days ago with septic shock
160. 6:36secondary to staff orus bacteremia and
161. 6:40cellulitis overnight she spiked another
162. 6:42fever to 39.1 in the absence of any
163. 6:45other new symptoms prompting a repeat
164. 6:48set of blood cultures subjectively this
165. 6:51morning she reports still feeling quote
166. 6:53crummy but is overall better than
167. 6:55yesterday and is in better spirits the
168. 6:58dmia present on admission is now
169. 7:00resolved her right leg pain uh is
170. 7:03improving but she still does not feel
171. 7:05well enough to walk around on it uh
172. 7:07independently she used her pin 5 Mig of
173. 7:10Oxycodone three times yesterday on exam
174. 7:14vitals from the past 24 hours include
175. 7:16the aention T-Max of 391 uh T current is
176. 7:2037.5 uh pulse 70 to 95 blood pressure
177. 7:24106 to 122 over 72 to 84 respiratory
178. 7:28rate 16 to 20 and O2 sat is 95% to 98%
179. 7:32on room a eyes and nose have been even
180. 7:35lungs are clear cardiac exam still on
181. 7:37remarkable including no no no murmurs no
182. 7:40evidence of endocarditis on extremity
183. 7:42exam the warmth and tenderness of the
184. 7:44right leg has reced it to just below the
185. 7:46knee which she can now Bend freely
186. 7:48without joint pain on Labs her right
187. 7:51count is 12.5 uh from 13 yesterday and
188. 7:55Crum 1.7 from uh 2.0 an Gap remains
189. 7:59normal and no new lactate levels within
190. 8:01the last 24 hours emission blood
191. 8:04cultures were updated this morning and
192. 8:05now identified as Mera uh tte yesterday
193. 8:09had good views and revealed normal
194. 8:11cardiac function with no vegetations or
195. 8:13other valve problems uh there is no
196. 8:15other new Imaging so in summary Miss
197. 8:18White is a 38-year-old woman who
198. 8:20presented with septic shock secondary to
199. 8:22mmia and cellulitis Complicated by acute
200. 8:26lung injury in ATN which required a 1day
201. 8:29stay in the ICU for critical care
202. 8:31monitoring but improved without a need
203. 8:33for vasor pressors or positive pressure
204. 8:36ventilation problem one uh merab
205. 8:39bacteremia given her Improvement and the
206. 8:41final ID of the organism we are
207. 8:43narrowing antibiotic therapy from van
208. 8:46plus sephine to just van alone we're
209. 8:48currently planning on a 14-day course of
210. 8:50the van which will require a pick once
211. 8:53blood cultures are negative given that
212. 8:55the tte from yesterday was a highquality
213. 8:57study and completely nor normal uh and
214. 9:00the lack of any per uh peripheral
215. 9:02findings of endocarditis we're holding
216. 9:04off on a te but if her repeat blood
217. 9:07cultures are persistently positive we'll
218. 9:10discuss this decision with
219. 9:12ID problem two uh is pain control uh I
220. 9:16discussed with this white options for
221. 9:17treating her right leg pain and we are
222. 9:20in agreement for continuing the uh
223. 9:22current plan which is Round the Clock
224. 9:24Tylenol and PRN oxy 5
225. 9:27q6 problem three is her acute uh kidney
226. 9:30injury secondary to ATN I'm reassured
227. 9:33that the creatinine is mildly improved
228. 9:35today and urine output is good no
229. 9:38specific Diagnostics or treatment
230. 9:40indicated we will continue to monitor
231. 9:42with strict eyes and nose and daily
232. 9:44chemistry panels the next problem is her
233. 9:47acute lung injury as her O2 requirement
234. 9:50and lung exam are both normal this
235. 9:52appears resolved which is what we would
236. 9:54expect given her sepsis Improvement as
237. 9:56well uh last is her dispo I anticip that
238. 9:59she'll be discharged back home pending
239. 10:02placement of her pick line which will
240. 10:03take at least another two days while
241. 10:05waiting on the repeat blood cultures in
242. 10:07the meantime We are continuing PT and OT
243. 10:10and encouraging her uh her to get out of
244. 10:12bed as much as tolerated