Subjective, Objective, Assessment and Plan Note for a Car Accident Victim (Case Study Sample)
the TASK IS A SOAP NOTE FOR A CASE STUDY:
Patient Situation
Mick Smith is a 17-year-old male brought to the emergency department in an ambulance. Apparently, he was at a party with friends but left early because he was feeling tired and unsteady on his feet. Outside, he fell on the left lawn after tripping on the grass. A car that was backing from the driveway, leaving the party, ran over him.
Patient Situation
Mick Smith is a 17-year-old male brought to the emergency department in an ambulance. Apparently, he was at a party with friends but left early because he was feeling tired and unsteady on his feet. Outside, he fell on the left lawn after tripping on the grass. A car that was backing from the driveway, leaving the party, ran over him.
Collect cues/information
Stated Range
Normal Range
Airway
Patent airway
A patent airway is always the priority (WHO, 2020).
Breathing
Normal breath sounds bilaterally.
RR 22
The respiratory rate refers to the number of breaths per minute while at rest and it is related to the brain's oxygen needs. In a situation where the blood oxygen is low or plasma's carbon dioxides level is high, the body breathes more. Evidence shows that one's respiratory rate is crucial in predicting serious medical events (Hayden et al., 2016). The normal respiratory rate for a 17-year-old is 12-16 b/m. A respiration rate of 22 is elevated, and it is evidence of an ongoing abnormality due to an imbalance in the body's oxygen demand and supply.
Circulation
SpO2 96% on RA
HR 126 with sinus tachycardia on cardiac monitoring
BP 88/60 mmHg
T-35°C
An oxygen level of 96% RA is within the normal range of 94-99% (Hayden et al., 2016).
Heart rate is the number of times the heart beats in one minute to supply the body with the required nutrients and oxygen. Tachycardia, a heart rate of over 100 b/m means that the heart is beating faster in response to an underlying abnormality (Hayden et al., 2016). A heart rate of 126 for the patient is a response to a deviation in the body’s normal physiology. It is the body’s compensatory mechanism to meet the tissue’s oxygen demand.
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