SOAP Note Analysis and Treatment Plan: Lab Assessment Test

This document presents a SOAP (Subjective, Objective, Assessment, Plan) note based on a laboratory assessment test for a 56-year-old male patient, Mr. John Wilson. The subjective assessment reveals complaints of chest pain, fatigue, and dizziness, along with allergies to Paracetamol. The objective assessment includes vital signs such as elevated blood pressure (168/100) and a high blood sugar level (250 mg/dL), alongside diagnostic tests like an HgA1C of 9.5%. The assessment summarizes a medical diagnosis of abnormally high blood sugar, lipid levels, and blood pressure, with a differential diagnosis of potential cardiovascular complications. The therapeutic goals include controlling blood sugar levels and preventing cardiovascular complications. The plan outlines diet recommendations (2000 calories per day), physical activity, and pharmacotherapeutics using Metformin 500mg, alongside regular monitoring of blood glucose levels. The document emphasizes the importance of laboratory diagnostic tests in diagnosing diseases, formulating treatment plans, and monitoring treatment progress. It references various studies on the effectiveness of laboratory tests and the importance of interpreting results accurately for effective patient care, concluding with a reference list.

Running head: LABORATORY ASSESSMENT TEST
LABORATORY ASSESSMENT TEST
TITLE
Name of Student:
Name of University:
Author’s Note:

1LABORATORY ASSESSMENT TEST
SOAP NOTES
Name: Mr John
Wilson
Age: 56 years Gender: Male Contact 12345678
Subjective assessment
Sign and symptoms Patient complains for pain in chest, fatigue
and dizziness
Allergies Is allergic to Paracetamol
Medication Metaformin 20mg
Bumetanide 40mg
Past medical history Obese since 5 years, hypothyroisim
Event leading up to emergency Sugar level is elevated and not being
controlled.
The pain is rising and radiating to left arm
Objective assessment
Time of assessment 1200 hrs
Level of consciousness
General appearance
Patient is alert and responsive
Well nourished
Vitals signs
Blood pressure
Regular pulse
Serum creatinine
BMI
Albumin excretion
Blood sugar
168/100
84 bpm
1.2mg/dl
27
250mg/day
250 mg/dL

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Blood lipid value 300mg/dL
Diagnostic test HgA1C of 9.5%
Breathing
Circulation
Normal
Normal
Assessment summary
Medical diagnosis- Abnormal high blood sugar, lipid level and blood pressure.
Differential diagnosis: cardiovascular complication due to chest and left arm pain.
Risk factors- obesity, A1C>/=5.7%, hypertension
Therapeutic goal-
 Control of abnormal blood sugar level
 Prevention of prevalence of cardiovascular complication and diabetes, by maintaining
healthy cholesterol level. LDL should be <100
No medication has been prescribed. There is the requirement of the therapy to lower the level
of A1C and managing the abnormal level of blood glucose by giving insulin and other related
complication.
Plan
Therapeutics- diet recommendation (2000 calories per day), physical activities for 30 minutes
per day and regular monitoring the BGL by glucometer.
Pharmacotherapeutics- Metformin 500mg. It is used to decrease the secretion of glucose and
its absorption in liver and intestine respectively. Low dose is not effective in high blood sugar

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level, hence high dose is prescribe (Maruthur et al., 2016).
Laboratory diagnostic test- It is test which is performed to check the health of the
person and diagnose any related health issue or other condition. Laboratory diagnostics is the
procedure that involves the testing of sample of blood, urine and other substance of body
(Baratloo et al., 2015). It is use to regulate and determine the diagnosis of disease. It is used to
propose a plan of treatment and as an impact it evaluate the progress of treatment and keep a
regular monitoring of the disease overtime (Althubaiti, 2016). The blood test of the patient has
revealed that he is having diabetes and is at risk of developing heart disease. As per the
laboratory diagnostic, the treatment plan was formulated for the patient for healthy outcome.
It is crucial to follow up the clinical practice guideline for using the laboratory test with
objective to monitor the drug therapy in control of diagnosed disease which is known as
laboratory medicine practice guidelines. The nurse need to be mindful in interpreting the
laboratory test and validate it to communicate the result to clinician (LaRocco et al., 2016).
The SOAP note has help to become competent to relate the laboratory test with the
diagnosis of disease and this gives scope for future practice in the area of laboratory assessment
test. Thus becoming a future competent nurse who can comprehensively relates the vitals sign
and blood test for better planning of treatment.

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Reference
Althubaiti, A. (2016). Information bias in health research: definition, pitfalls, and adjustment
methods. Journal of multidisciplinary healthcare, 9, 211.
Baratloo, A., Hosseini, M., Negida, A., & El Ashal, G. (2015). Part 1: simple definition and
calculation of accuracy, sensitivity and specificity.
LaRocco, M. T., Franek, J., Leibach, E. K., Weissfeld, A. S., Kraft, C. S., Sautter, R. L., ... &
Cornish, N. E. (2016). Effectiveness of preanalytic practices on contamination and
diagnostic accuracy of urine cultures: a laboratory medicine best practices systematic
review and meta-analysis. Clinical microbiology reviews, 29(1), 105-147.
Maruthur, N. M., Tseng, E., Hutfless, S., Wilson, L. M., Suarez-Cuervo, C., Berger, Z., & Bolen,
S. (2016). Diabetes medications as monotherapy or metformin-based combination
therapy for type 2 diabetes: a systematic review and meta-analysis. Annals of internal
medicine, 164(11), 740-751.