SOAP

Terms:

casualty department - part of ER

analgesic - acting to relieve pain.

laparotomy - incision of the abdominal cavity

hypovolaemic - low volume

urea - Urea, also known as carbamide, is a safe, useful compound with a significant history. It is a naturally occurring molecule that is produced by protein metabolism and found abundantly in mammalian urine

SUBJECTIVE

• young man fit - marathon runner, celebrate - alcohol ++++
• confrontation - kicked in lower back below ribs several times, pain, passed small volume of dark brown urine, collapses

OBJECTIVE

• BP 80/40 mmHg
• PR 86/min
• RP 40/min
• anuric (no urine), hypovolaemic
• bloods - urea is grossly elevated, pH 7.2, sodium and potassium concentrations are raised

ASSESSMENT

• high rate of IPV in community, abdominal trauma and shock

PLAN

• prevent and manage trauma and shock appropriate, promotes safety in communities, resuscitate, treat shock, laparotomy and counselling