「Brain」は自分が使いやすいように自作で。

「Brain」というのは、患者さんのアセスメントの内容などを書き込むフォームです。「Brain sheet」と呼ぶ人もいるかもしれません。

自分が行く(働く）分野によって、Brainの内容は違ってきます。その分野によって、「Focus」するポイントが違うからです。ネット上に、書き込んで使用できるブランクのフォームを探すことが出来ますが、私はBrainは自分が使いやすいように作っていました。

というわけで、今回も作ってみたいと思います。

 

NICU(Newborn ICU/乳幼児集中治療室)でのBrain

以前「NICU（ニックユー）」という、乳幼児の集中治療室に実習に行ったことがありました。その時そこにいた乳幼児は、全員が顕著に小さい未熟児で、気持ち的に「恐る恐る」触るような、そんな感じでした。私はすごく緊張していました。

生徒のプリセプターとして付いて下さった看護師さんが、朝の説明が終わると「あ、そうそう、Brainが必要ね。はい、Brain。これに何でも書き込んで」と言って、紙を渡してくれました。見たら、それは真っ白なA4の紙でした。笑

私は声を出して笑ってしまって、この看護師さんが好きになりました。

 

今回Brainに書き込む内容は「SOAP」

今回Brainに書き込む内容は、略してSOAPです。お馴染みかと思います。

 

Subjective (what patient tells you/患者さんが言うこと)、Objective (physical exam)、Assessment、そしてPlan (Treatment Plan)です。

 

Subjective data – Chief Complaint, Present illness, Past Medical History, Family History, Personal & Social History, and Review of System (ROS)

Objective data – physical examination findings

Assessment – Positives & Negatives, Differential diagnoses (DDx), Dx

Plan – Medication, Patient Education (instructions for the patient)

 

Subjectives

Chief Complaint:

History of present illness – onset of s/s, duration of s/s, what makes it better/worse, any interventions at home? etc.)

Past Medical Hx:

Surgical Hx (year):

Family Hx:

Social Hx (drink, smoke, illicit drugs, etc.):

Allergies:

Medications:

Immunizations (Up to date, etc.):

ROS (Review of Systems)

General: Recent weight change, clothing size change, weakness, fatigue, fever, chills, night sweats

Eyes: Vision problem, redness, excessive tearing, double vision, spots, flashing lights, specks, pain, and eye pressure

Ear: Hearing problems, tinnitus, vertigo, earaches, discharge

Nose and sinuses: Nasal stuffiness, discharge, itching, nosebleeds, sinus trouble

Throat (Mouth and pharynx): Tooth decay, pain, gum bleeding, dentures, last dental exam, sore throat, dry mouth, hoarseness

Neck: Swollen neck glands, lumps, pain, stiffness in the neck

Breast: Lumps, pain, or discomfort, nipple discharge

Respiratory: Cough, sputum, hemoptysis, dyspnea, wheezing, pleurisy, last chest x-ray

Cardiovascular: “Heart trouble,” high blood pressure, SOB, palpitations, dizziness, orthopnea, paroxysmal nocturnal dyspnea, edema, past EKG test or other cardiovascular tests

Peripheral vascular: Intermittent claudication, leg cramps, vericose veins, past clots in the veins, swelling of lower legs or feet, skin color change in fingertips or toes during cold weather, swelling with redness or tenderness

GI: Trouble swallowing, heartburn, appetite, N/V, B/M pattern, change bowel habits, stool color and size, abd pain, pain with defecation, rectal bleeding, black or tarry stools, hemorrhoids, constipation, diarrhea, excessive belching, excessive gas, cramping

Urinary: Urgency, frequency, burning or pain during urination, polyuria, nocturia, hematuria, urinary infection, flank pain, incontinence. Males: reduced caliber or force of the urinary stream, hesitancy, dribbling.

Genital: Males – Discharge from penis, pain on the penis, testicular pain, STI or other concerns. Females – Age at menarche, regularity, frequency, and duration of periods, amount of bleeding, bleeding between periods, bleeding during or after intercourse, last menstrual periods, dysmenorrhea, premenstrual tension, vaginal discharge, itching, sores, lumps, past STI and treatment, number of pregnancies, complication of pregnancy, birth control methods, other concerns.

Musculoskeletal: Muscle or joint pain, stiffness, backache, joint pain with systemic s/s (fever, chills, rash, anorexia, weight loss, weakness)

Hematologic: Bruising or bleeding easily, anemia, past transfusions.

Skin – Rash, irritations, or redness

Neurology: Headache, numbness, tingling, dizziness, vertigo, fainting, lightheadedness, blackouts, weakness, loss of sensation, “pins and needles,” tremors, involuntary movements, seizures.

Psychiatric: Nervousness, depression, anxiety, memoty change, suicide attempts if relevant. 

 

Reference

Bickley, L. S. (2013). Bates’ guide to physical examination and history taking (11th ed.). Lippincott Williams & Wilkins. 

 

 

Objectives

Vital Signs: BP —-, HR —-, RR —-, O2 sat –%, Temp —-

HT. –’–”, Wt. —-lbs., BMI —-

 

Physical Exam:

Constitutional/General: alert and oriented, general appearence

HEENT

Head: Head and scalp normocephalic, normal hair distribution

Eyes: EOM intact, red reflex visualized, Pupils are in the center, ERRLA (equal, round, reactive to light, accomodation)

Ears: No tenderness, no erythema, no drainage. Tympanic membrane translucent in bilateral ears.

Nose: No erythema, no swelling of turbinate, no discharge, no crusting seen in bilateral nares

Throat and Mouth: No erythema, uvula in midline, no malodor, no tonsillar enlargement without exudates. Neck is supple, no enlarged cervical nodes.

Lungs: No cough, no wheezing,

Cardiovascular: Cap refill <2 sec, no murmur.

ABD: abdomen soft, no tenderness, no distension, B/S present in all four quadrants. No mass.

GU: no redness, swelling, or discharge. + pelvic tenderness

MSK: Full active ROM, gait is steady and balanced. No weakness. Muscle strength 5/5.

Neurological: Alert & Oriented, no tremors, no altered mental status. Memory intact. Deep tendon equal B/L +2

Psych: appearance (neat, , behavior and speech appropriate. Mood and affect normal and appropriate to situation. Patient is pleasant and cooperative