Comparison between Subjective, Objective, Assessment and Plan Essay.
Subjective data in a SOAP note describes the feelings of a patient or a close family member, personal views, client’s interactions and experiences. Objective data in the SOAP note on the other hand shows the measures and test results performed as well as the objective of the physician in accordance to the recorded observations (Varpio et al, 2018). In addition, the assessment section is where the therapist documents their thoughts on salient issues as well as diagnosis and differential diagnosis based on information previously collected in subjective and objective section. Lastly, the plan component is the section where the physician outlines a plan for each problem numbered in accordance to urgency and severity of the therapy.Comparison between Subjective, Objective, Assessment and Plan Essay.
The musculoskeletal system provides stability, support, movement and form to the body. Entirely, the musculoskeletal is made up of cartilage, ligaments, muscles, skeleton, joints, skeleton and the connective tissues that bind and support together the organs and the tissues together (Varpio et al, 2018). In the subjective data the musculoskeletal of the 5 year old kid shows pain on the elbow upon movement. The elbow is deformed and swollen but denies back pain and muscle cramping. In the objective data, the musculoskeletal information of information shows that the alignment of the major joints of the left elbow are asymmetrical.Comparison between Subjective, Objective, Assessment and Plan Essay. The left elbow also shows erythema and ecchymosis. In addition, the elbow is tender, shows color change and has edema on palpation. Motion testing showed absence of restriction. In addition, the patient showed no cyanosis and the bilateral extremities showed no single sign of edema. Therefore, 2 & radial pulses + 2 noted bilaterally + pedal pulses. On assessment, the young boy was diagnosed with elbow injury ICD 10 S59.901. The differential diagnosis was posterior elbow dislocation S53.025, lateral condylar fracture S42.45, radial head or neck fracture S52.13 and supracondylar fracture S42.413D. The plan for the patient is to take NSAIDs to relive the pain, an x-ray of the left arm and icing the elbow at least four times daily each session to take 20 minutes. The patient will also undergo immobilization with a posterior long arm splint and a physical therapy that will help in the restoration of range motion into the cast. Lastly, the client will be referred to an orthopedic for further checkup.Comparison between Subjective, Objective, Assessment and Plan Essay.
Description of Illness, Diagnosis, Pertinent to Age and Visit
The patient complained about moderate pain on his left elbow which the mother thought was just a sprain caused a fall that happened when playing football. The young boy was not taken to an emergency department but was put on Tylenol the pain reliever. On waking up the following morning, the boy woke up with a swollen and painful arm that could not move easily. After thorough physical examination and assessment by the physician, EW was diagnosed with elbow injury. Elbow injury is common to boys aged between 5 to 10 years since this is their exploration age.Comparison between Subjective, Objective, Assessment and Plan Essay.
There are no pharmacodynamics applicable in the pediatric patient case since he is not on any previous medication.
The Recommended Treatment Guidelines for Elbow Injury
Elbow injuries related to sports in young children are a substantial public health problem. While playing and participating in sports is important to pediatric for physical activity promotion it is important to assess them after every activity (Lieberman, 2019). Most elbow injuries and pains improve with simple home remedies including resting, protect the affected area from further injury, placing an ice pack three times a day for around 20 minutes and compressing using a bandage to prevent swelling. Severe elbow injuries are treated with physical therapy, steroid injections, elbow padding, braces and immobilization. Further, elbow injuries can be treated by exercising the elbow to increase the range of motion, to relieve pain, to strengthen the muscles and to reduce inflammation.Comparison between Subjective, Objective, Assessment and Plan Essay.
Lessons learnt from this Case and whether anything would have been done differently
Parents should always take orthopedic complaints from their children without making assumptions about the possible injury. In addition, when an arm is not moving freely, that is an indication of a possible injury and emergency care is required (Haarbauer-Krupa et al, 2018). Parents should also have a thorough check of their children after a long day playing in the field to check for any injuries. The patient was managed in the right way, no more treatment was required. However, a patient education was necessary to advise the patient on how to take of himself while playing.Comparison between Subjective, Objective, Assessment and Plan Essay.
There was no any culture sensitive action performed on the patient and therefore there is no any needed intervention required. Comparison between Subjective, Objective, Assessment and Plan Essay.