In medical documentation, the SOAP note is a widely used format that allows healthcare professionals to organize patient information effectively. SOAP stands for Subjective, Objective, Assessment, and Plan SOAP note example poisoning case. In poisoning cases, quick identification and action are crucial, and a well-structured SOAP note plays a significant role in guiding diagnosis and treatment. Below is an SEO-optimized and educational breakdown of a SOAP note example in a poisoning case, tailored for healthcare students and professionals.
Subjective
The subjective section includes the patient’s reported symptoms and history. In this example, a 35-year-old female presents to the emergency department complaining of nausea, vomiting, abdominal cramps, dizziness, and confusion. She mentions that she ingested an unknown quantity of insecticide two hours prior to her arrival in a suicide attempt. She was found by a family member who immediately brought her to the hospital. The patient admits to feeling emotionally distressed over the past week and says this is not her first time attempting self-harm. She reports a burning sensation in her throat and difficulty breathing. No known drug allergies are reported, and her past medical history includes depression and mild asthma.
Objective
The objective section records measurable clinical findings. On examination, the patient appears anxious and disoriented. Her vital signs are: blood pressure 90/60 mmHg, heart rate 110 bpm, respiratory rate 24 breaths per minute, and oxygen saturation 91% on room air. Pupils are constricted and reactive to light. Lung auscultation reveals bilateral wheezing. Abdominal examination shows mild tenderness without rigidity. ECG shows sinus tachycardia. A tox screen is pending, but preliminary tests reveal low serum cholinesterase levels, indicating organophosphate poisoning. The nursing staff also observed excessive salivation and sweating. Lab results show mild metabolic acidosis, and chest X-ray indicates mild pulmonary edema.
Assessment
Based on the subjective complaints and objective findings, the clinical assessment concludes with a diagnosis of acute organophosphate poisoning. This is supported by the patient’s history of insecticide ingestion, presence of muscarinic symptoms (salivation, sweating, miosis), and low cholinesterase levels. The differential diagnoses include carbamate poisoning and opioid overdose, but the combination of symptoms and lab values makes organophosphate toxicity the most likely diagnosis. The patient’s mental state also suggests a need for psychiatric evaluation to assess suicide risk.
Plan
Immediate stabilization is the top priority in the treatment plan. The patient was admitted to the ICU for close monitoring and supportive care. Oxygen therapy was initiated, and intravenous fluids were administered to manage hypotension. Atropine was given in incremental doses to counteract muscarinic symptoms. Pralidoxime (2-PAM) was administered as an antidote to reactivate cholinesterase. Activated charcoal was considered but withheld due to the time since ingestion and risk of aspiration. Cardiac monitoring and serial cholinesterase levels are scheduled to assess treatment response. A psychiatric consult has been requested for suicide risk assessment and further mental health management. The family was counseled regarding the situation and provided with emotional support resources.
Follow-up labs will include arterial blood gases, complete blood count, and liver and kidney function tests. The patient will be monitored for potential complications such as respiratory failure, arrhythmias, and delayed neurotoxicity. If clinical improvement is observed over the next 48 hours, we will begin to taper medications and consider discharge planning with outpatient psychiatric support. Poison control will also be contacted for further guidance.
Conclusion
This SOAP note example for a poisoning case demonstrates the effectiveness of structured documentation in emergency toxicology. The SOAP format provides clarity and ensures all critical aspects of the case are addressed systematically. In poisoning scenarios, timely intervention based on accurate documentation can significantly improve patient outcomes. For healthcare professionals, mastering the SOAP note is essential for both legal documentation and interdepartmental communication. This case highlights the importance of clinical awareness, rapid decision-making, and compassionate care in the treatment of acute poisoning.
