Soap note

Case Study
Ms. Sunshine, a 54-year-old African American woman, is diagnosed with coronary artery disease (CAD). Her main coronary artery is 90% occluded. The resulting decrease in blood flow provides insufficient oxygen for the production of ATP. There is well-established evidence that early intervention of reopening the occlusion significantly improves the outcome of CAD patients.
In the case of Ms. Sunshine, the possible early use of thrombolytic intervention pre-PCI may assist in returning adequate, highly oxygenated blood back to the almost-occluded area of her myocardium, but further information is needed to determine if the cellular injury that has already occurred from the lack of oxygen leading to hypoxia to the area of the myocardium will be reversible. Ms. Sunshine decided to travel from Denver to Boston to see her son, Mitchell, and her new grandson. Mitchell left Denver two years ago to take a position at one of the city hospitals and has not seen his mother since he left. He is studying at Southern New Hampshire University to be a master’s-prepared nurse. Mitchell has been quite busy with a new position, a new baby, as well as taking the advanced pathophysiology course. Mitchell meets his mother at the airport, and he notices that Ms. Sunshine is short of breath and looks very tired and anxious. When he asks her whether she has chest pain, she denies chest pain but admits that she did have some chest discomfort before leaving the Denver airport. Mitchell knows that his mother has hypertension and suspects that she has not been faithful about taking her medications. He calls 911 and takes his mother to the hospital directly, despite Ms.Sunshine’s objections. She admits to him that she has had dyspnea and fatigue for the past week but thought that she might have the flu or that perhaps the long trip had made her tired and caused some breathing problems. Mitchell has a slight delay negotiating his way out of the airport to follow the route to the nearest emergency department. Ms. Sunshine has been triaged, and a series of diagnostic tests have been ordered and are being processed. Mitchell finds his mother lying in bed with the head of the bed elevated, an oxygen mask in place, and IV infusing into her right arm, and she is connected to telemetry and being attended to by the emergency department staff. Mitchell informs the ED staff that his mother is allergic to penicillin and shellfish. He reiterates that she does not always take her BP medication. A review of Ms. Sunshine’s medical history with her son reveals the following:
 Hypertension
 Hyperlipidemia
 Insomnia
 Episodes of Anxiety since husband’s death last year
Other pertinent data reveled during the interview with Mitchell finds that Ms. Sunshine lives alone in Denver in a one bedroom ground-level garden apartment
with group of fellow widowers in the neighborhood who she sees frequently. She is known to socialize with the group at least once a week and admits to 1 glass
of red wine per night with dinner. She has a remote history of smoking ½ pack of cigarettes per day, but quit 10 years ago.
Current Vital Signs: BP 148/88 L arm, pulse 88 regular, RR 16, Temp; 36.9°C oral
You now take the role of the master’s-prepared nurse in the emergency department and have received the following diagnostic results:
Relevant lab values (assume all other lab values are normal)
Na = 138; K = 6.2; Cl = 106; BUN = 28; Cr = 2.4; Cholesterol = 248 mg/dl, LDL = 160 mg/dl
Date 3/15 3/15 3/16 3/16
Time 1700 0000 0600 1400
CPK 778 966 598 103
CPK-MB 12 15 10 2
Troponin T:
mcg/L
0.03 0.5 1 1
Relevant diagnostic tests:
Chest x-ray: lungs clear, tortuous aorta, cardiomegaly
ECG: inferior MI; ST-segment elevation, T wave elevation, pathologic Q waves.

prompt: use the information in this case study to prepare a SAOP note document showing the S: subjective information, O: objective information, A: Assessment, P: plan,