In clinical toxicology, effective communication and thorough documentation are essential for managing poisoning cases. The SOAP note format—Subjective, Objective, Assessment, and Plan—is a widely used method to standardize medical documentation. This structure ensures that healthcare professionals present clear, concise, and organized clinical information. In cases of poisoning, a detailed SOAP note can help track symptoms, treatment decisions, and follow-up steps SOAP note example poisoning case, ultimately improving patient care outcomes. Below is a detailed SEO-optimized example of a SOAP note for a poisoning case.
Subjective
A 24-year-old female presents to the emergency department with complaints of nausea, vomiting, dizziness, and confusion. She reports ingesting an unknown quantity of acetaminophen tablets approximately six hours before arrival. The patient admits to taking the medication intentionally in a suicide attempt following a personal dispute. She has no significant past medical history and denies any history of drug allergies. The patient is visibly anxious and has difficulty recalling the exact time and amount of ingestion. Family members confirm finding an empty 100-tablet bottle of 500 mg acetaminophen in her room.
Objective
On initial examination, the patient appears pale and slightly diaphoretic. Her vital signs are as follows: temperature 98.9°F, heart rate 108 bpm, respiratory rate 22 breaths per minute, blood pressure 110/70 mmHg, and oxygen saturation 97% on room air. She is alert but intermittently confused. Pupils are equal and reactive to light. Cardiovascular and respiratory examinations are unremarkable. Abdominal examination reveals mild right upper quadrant tenderness without guarding or rebound. No signs of hepatic encephalopathy are present at this time.
Laboratory results include an elevated serum acetaminophen level of 180 mcg/mL drawn approximately six hours post-ingestion, which falls within the toxic range on the Rumack-Matthew nomogram. Liver function tests reveal slightly elevated AST and ALT. Prothrombin time is within normal limits, and renal function is preserved. Blood glucose and electrolytes are within normal ranges.
Assessment
This is a case of acute acetaminophen poisoning in a young adult female, likely secondary to intentional overdose. The elevated acetaminophen level confirms toxicity, although liver enzyme levels are only mildly increased at this point. Given the time since ingestion and current lab findings, the patient is at risk for hepatotoxicity if left untreated. Her clinical status remains stable, but she requires immediate intervention to prevent liver injury.
Plan
- Initiate N-acetylcysteine (NAC) therapy immediately as per the acetaminophen toxicity protocol. The initial loading dose is 150 mg/kg IV over 60 minutes, followed by maintenance doses as indicated.
- Admit the patient to the medical unit for continuous monitoring and supportive care. Monitor vital signs, mental status, and hepatic function closely.
- Repeat liver function tests, INR, and acetaminophen levels every 12 hours to evaluate response to NAC therapy.
- Consult psychiatry for mental health evaluation and suicide risk assessment. Schedule follow-up care and counseling based on recommendations.
- Provide IV fluids to maintain hydration and monitor for signs of worsening toxicity, including changes in mental status or increasing liver enzymes.
- Educate the patient and her family about the risks of acetaminophen overdose and the importance of timely intervention.
- Arrange social work involvement to provide support resources, including mental health services and crisis intervention.
This SOAP note example illustrates a structured and professional approach to documenting a poisoning case. By adhering to the SOAP format, healthcare providers ensure that all critical aspects of patient care are captured effectively. In poisoning scenarios, rapid identification of toxic agents, accurate interpretation of diagnostic tests, and timely treatment initiation are essential to prevent complications. Utilizing standardized documentation not only aids in patient management but also supports interdisciplinary collaboration among healthcare teams. Through this approach, better clinical outcomes and patient safety can be achieved in emergency toxicology settings.