SOAP Note Discussion Paper

SOAP Note Discussion Paper

SOAP Note Discussion Name Institutional Affiliation Instructor Course Title Date Soap Note Discussion Subjective: CC: “I fainted a few days ago.” Differential Diagnosis: Orthostatic syncope, Neurally-mediated Syncope, Arrhythmic syncope, Structural syncope HPI: A 60-year-old female patient presents to the clinic following her syncopal episode a few days ago. According to the patient, she was in her normal health state allowing her to have a fairly active life, until a few days ago when she was in the kitchen preparing some breakfast and passed out. In the patient’s statement, the husband later found her lying on the floor SOAP Note Discussion Paper.

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Unfortunately, she was in a state of confusion and could not have any fall recollection. However, the patient thinks she lost consciousness only for a few minutes or seconds when the husband found her. Following the syncopal episode, the patient decided not to seek care at the ER because she felt fine regardless of the fall. Also, the patient denies any changes in her following the entire syncopal episode. Meaning, the patient denies any chest pain, nausea, vomiting, or even diarrhea. She also denies headaches after her fall. Since the episode experience, the patient likes riding her tractor; nonetheless, she fears driving since syncope might reoccur and even cause an accident. Therefore, she comes to the clinic to know more about the cause of her syncopal episode without aftermath injuries despite her fall SOAP Note Discussion Paper