SOAP TEST

Subjective: Patient reports they have been consistently implementing their self-management priorities, specifically focusing on regular exercise and dietary adjustments as discussed in the initial assessment. They report feeling more energetic and have noticed a positive impact on their mood. Patient reports a significant improvement in their functional tolerance, now able to walk for 30 minutes without experiencing any significant pain or fatigue, compared to 15 minutes at the previous assessment. Patient reports a reduction in their shortness of breath during physical activity, correlating with the improved functional tolerance. They also report a decrease in the frequency of chest pain. Patient has not reported any adverse events impacting their recovery progression. Patient reports positive feedback from the physiotherapist regarding their improved posture and gait, and they are actively incorporating the psychologist's recommended relaxation techniques into their daily routine. Objective: Patient Specific Functional Scale score update for Goal 1 (Walking): 8/10, Goal 2 (Climbing stairs): 7/10, Goal 3 (Household chores): 6/10. Exercising Heart Rate tolerance update: Patient's heart rate during exercise remains within the target range of 110-130 bpm without any adverse symptoms. Resting HR: 72 bpm. Patient presents as alert and oriented, engaging actively in the conversation. They recall the content of the previous appointment accurately. Physically, the patient appears well-groomed and in good spirits. They are not using any assistive aids. Treatment: Discussed the physiotherapist's feedback on the patient's posture and gait, and integrated this into the treatment plan by focusing on exercises to improve core strength and balance. The psychologist's relaxation techniques were also incorporated by encouraging the patient to practice them before and after exercise. Treatment dosing of function for each goal: Walking - 30 minutes, Climbing stairs - 2 sets of 10 repetitions, Household chores - 1 hour. Treatment dosing of exercising Heart Rate: Patient to maintain heart rate between 110-130 bpm during exercise. Active symptom management strategies discussed: Patient was reminded to stop and rest if they experience any chest pain or shortness of breath during exercise. They were also advised to use their inhaler as needed. Integration of other IDT members: The physiotherapist is providing guidance on exercise techniques, and the psychologist is helping the patient manage stress and anxiety. The purpose of integration is to provide holistic care and address all aspects of the patient's health. No other ACC service direction is being sought. The case manager is aware of the patient's progress. Analysis: The patient's recovery trajectory is positive, with improvements in functional tolerance, symptom management, and overall well-being. Factors impacting the trajectory positively include the patient's adherence to the treatment plan, the support from the IDT, and the patient's positive attitude. No negative factors were identified. Expectation of issues/barriers that will be addressed by other IDT members: The physiotherapist will continue to address any musculoskeletal issues, and the psychologist will help the patient manage any psychological barriers to recovery. Plan: Next appointment date: 8 November 2024. Actions required: * Patient: Continue with the home exercise program (HEP), practice relaxation techniques, and monitor symptoms. * Clinician: Review the patient's progress, adjust the treatment plan as needed, and communicate with the IDT.