Hospital Follow up Soap Note
Hospital Note
Hospital Follow-up Note on Patient Progress
Prepared by: Jane Smith, ApexArt Innovations
Date: June 11, 2050
This document is a comprehensive Hospital Note prepared for the purpose of tracking patients' progress, treatment, and any possible changes in their condition during their stay at ApexArt Innovations' medical facility.
Subjective
The patient cited an increase in pain levels, with discomfort being primarily concentrated in the lower back region. There were intermittent bouts of nausea, although no instances of vomiting were reported. Appetite remains low, and sleep patterns continue to be disrupted.
Objective
Upon examination, the patient’s vitals were recorded as follows:
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Temperature: 98.7 F
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Heart Rate: 105 bpm
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Blood Pressure: 140/90 mmHg
The patient’s laboratory tests show a slight increase in white blood cell count, potentially indicating an infection. Further diagnostic tests will be required for a comprehensive analysis.
Assessment
The symptoms and physical examinations indicate a potential lower disc problem, with a possible infection that may require additional plans for management. The patient's current medication regime does not seem to be effectively managing the pain and feel more diagnostic investigations are warranted.
Plan
Adjustments to the patient's current treatment strategy are recommended. These adjustments include the initiation of a more powerful analgesic, coupled with physiotherapy sessions to help alleviate some of the lower back pain.
We will also conduct more comprehensive diagnostic tests towards identifying the potential infection source. The patient will remain under close supervision until there is visible improvement in the condition.
This Hospital Note provides a snapshot of the patient's status on the date of the report and will serve as a guide for future medical interventions. It will be continually updated to inform ongoing treatment decisions.
