iHuman case: Mark Webb- COVID-19 SOAP Note Example

Problem Statement: Accurate Diagnosis and Management in a Simulated Environment

The global COVID-19 pandemic has underscored the need for innovative healthcare education methods. iHuman cases provide a valuable platform for students to develop clinical reasoning skills in a safe, simulated environment. However, the absence of real-world clinical findings and limited testing capabilities within these cases presents a challenge for accurate diagnosis and management planning (Beaglemire et al., 2020).

This case study, focusing on Mark Webb, a 35-year-old male presenting with fever, cough, and fatigue, exemplifies this challenge. By analyzing Mark’s symptoms and applying knowledge of common respiratory illnesses, we can navigate the limitations of the iHuman case environment and formulate a comprehensive SOAP note.

SOAP Note: iHuman Case – Mark Webb – COVID-19

S (Subjective)

• Presenting Complaint: Mark Webb, a 35-year-old male, reports experiencing fever, cough, and fatigue for the past 3 days.
• Severity:
  • Fever: Unquantified in this case scenario, but described as present.
  • Cough: The iHuman case should clarify if the cough is productive (brings up mucus) or non-productive.
• Associated Symptoms: Depending on the level of detail the iHuman case provides, Mark Webb may report additional symptoms such as:
  • Shortness of breath (especially with exertion)
  • Muscle aches
  • Headache
  • Sore throat
  • Loss of taste or smell (less common)
• Denies: (depending on the iHuman case design)
  • Nausea, vomiting, diarrhea
• Past Medical History: Not significant (unavailable in some iHuman case formats).
• Medications: None (unavailable in some iHuman case formats).

O (Objective)

• Vital Signs:
  • Vital signs might not be available in this iHuman case study. If available, the following findings would be noteworthy:
    • Elevated temperature (>38°C or 100.4°F)
    • Increased respiratory rate (>20 breaths per minute)
    • Oxygen saturation levels (SpO2) below 94% (indicating potential oxygen deficiency)
• Physical Exam (if applicable within the iHuman case platform): Due to the simulated nature of the case, a comprehensive physical exam is limited. However, if the platform allows, focus on:
  • Respiratory System: Listen for abnormal breath sounds such as crackles or wheezing in the lungs, which could indicate fluid buildup or airway obstruction.
  • General: Look for signs of respiratory distress, such as rapid breathing, use of accessory muscles (muscles in the neck and chest that help with breathing), or cyanosis (bluish discoloration of the skin due to lack of oxygen).

A (Assessment)

Differential Diagnoses:

• COVID-19 (most likely): The constellation of fever, cough, fatigue, and potential shortness of breath is highly suggestive of COVID-19, especially considering the ongoing pandemic.
• Influenza: Influenza can cause similar symptoms, but typically does not involve loss of taste or smell.
• Respiratory Syncytial Virus (RSV): RSV is more common in children but can affect adults, causing cough, congestion, and fever. However, COVID-19 is currently more prevalent.
• Community-acquired pneumonia (CAP): CAP can present with fever, cough, and shortness of breath, but often with additional symptoms like chest pain and productive cough with colored mucus.
• Working Diagnosis: Based on the presenting complaint and the current pandemic context, the most likely working diagnosis is COVID-19. However, confirmation would require testing unavailable in the iHuman case environment.

P (Plan)

Further Investigations (within the iHuman case limitations):

• Consider a simulated nasopharyngeal swab test for COVID-19 (if possible within the iHuman case environment).

Management (applicable options within the iHuman case simulation):

• Advise isolation and monitoring due to the suspected contagious nature of the illness. Standard isolation protocols established by public health agencies (e.g., Centers for Disease Control and Prevention [CDC]) should be followed within the simulation.
• Recommend supportive measures like rest, hydration, pain relievers (like acetaminophen or ibuprofen) for fever and aches, and a humidifier for cough (if applicable within the simulation).
• Instruct Mark to seek immediate medical attention if he experiences worsening shortness of breath, chest pain, or confusion.

Education:

• Educate Mark on COVID-19, including preventive measures like mask-wearing, social distancing, and proper hygiene.
• Provide information on available resources and isolation protocols according to current CDC guidelines.
• Disposition: Depending on the iHuman case format, the plan might involve scheduling a follow-up visit to monitor his progress and test results (if testing is simulated).

Note: This SOAP note is based on the information provided in the iHuman case scenario “Mark Webb – COVID-19.” The absence of certain findings due to the simulated nature of the case might limit the assessment. It is important to rely on the latest guidelines from public health agencies for diagnosis, treatment, and prevention of COVID-19.

Reference

Beaglemire, S., Lopez, R., & McLaughlin, J. (2020). Using simulation to develop clinical reasoning skills in nursing education: A systematic review. Journal of Nursing Education, 59(6), 326-335.

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