Read the case study. Write a progress note using the SOAPIER format. SJ came to the ER you are working at with complaint of severe pain in his left leg. When you asked him what happened, he said “I was sled riding in the snow with some friends. I lost control and went over the hill and hit a tree. My leg is killing me.” You do an assessment. SJ is alert and oriented to person, place and time. He has no known allergies (NKA).Skin is warm and dry. Color appropriate for ethnicity. Neuro checks are normal. Denies hitting his head. Has full range of motion in both arm and right leg. EMS has a stabilizing splint on his right leg. Bilateral toes are pink and capillary refill is quick to return. Distal extremities pulses are strong and bounding. Bowel sounds are positive in all four quadrants. Vital signs are 97.8 orally. Heart rate is 110 and regular. Heart sounds S1 and S2 heard. Respirations are 24 and unlabored. Lung sounds are clear. Blood pressure is 172/96. He asks “Please can you give me something for pain?” Rates his pain a “10” on the 0 -10 numeric scale. You give him 4 milligrams of morphine IV as prescribed by the physician. The xray results come back and he has a complete fractured tibia. He is admitted to the medical/surgical unit and scheduled for surgery tomorrow. Report given to RN “Mary” on the medical/surgical unit.

Progress Note

Patient: SJ
Age: N/A
Gender: N/A

Date of Admission: [Date]
Date of Progress Note: [Date]

Subjective:
SJ presented to the emergency room (ER) complaining of severe pain in his left leg. He reported that he had been sled riding in the snow with his friends when he lost control and collided with a tree. According to SJ, his leg has been causing him significant distress.

Objective:
During the assessment, SJ appeared alert and oriented to person, place, and time. There were no known allergies reported (NKA). Upon examination, his skin was warm and dry, with an appropriate color for his ethnicity. Neurological checks revealed no abnormalities. SJ denied hitting his head during the incident. He demonstrated full range of motion in both his arms and his right leg. The emergency medical service (EMS) had already applied a stabilizing splint to his right leg. Bilateral toes were observed to be pink, and capillary refill was quick. Distal extremities pulses were strong and bounding. Positive bowel sounds were detected in all four quadrants. Vital signs recorded an oral temperature of 97.8°F. SJ’s heart rate was 110 beats per minute and regular. Heart sounds S1 and S2 were audible. Respiratory rate was 24 breaths per minute, with unlabored breathing. Lung sounds were clear upon auscultation. Blood pressure measured at 172/96 mmHg.

Assessment:
SJ has provided a clear account of sled riding in the snow resulting in a collision with a tree, which is consistent with his presenting complaint of severe pain in his left leg. The physical examination revealed no neurological deficits, suggesting that the injury may be isolated to the lower extremity. The EMS had appropriately immobilized his right leg with a stabilizing splint, ensuring stability and minimizing further injury.

Plan:
In response to SJ’s request for pain relief, 4 milligrams of morphine were administered intravenously as prescribed by the physician. The x-ray results indicated a complete fracture of the tibia. Consequently, SJ is scheduled for surgery tomorrow and has been admitted to the medical/surgical unit. A thorough report has been provided to RN “Mary” on the medical/surgical unit to ensure continuity of care.

Education:
SJ should be informed about the upcoming surgery and its implications. Explanation of the procedure, expected outcomes, and post-operative care should be provided to alleviate any anxiety and ensure informed decision-making.

Response:
SJ’s pain has been addressed with the administration of morphine. The fracture of the tibia has been identified through x-ray, and he has been scheduled for surgery, signifying the appropriate management of his condition. Admitting SJ to the medical/surgical unit allows for closer monitoring and prompt intervention post-surgery.

Referrals/Consults:
Physician: To coordinate and oversee the surgical intervention, assess pre-operative clearance, and advise on post-operative care.
Orthopedic Surgeon: To perform the surgery and provide specialized expertise in managing the fracture.
Anesthesia: To provide anesthesia services during the surgical intervention.
Physical Therapy: To assist with post-operative rehabilitation and optimize functional recovery.
Pharmacy: To review and provide medication orders based on the surgical plan.

Follow-Up:
SJ should be seen by the medical/surgical unit nursing staff for ongoing pain management, monitoring of vital signs, and provision of post-operative care. Regular assessments and documentation should be performed to track SJ’s progress throughout his hospital stay.

Respectfully submitted,
[Your Name]
[Date]