A SOAP note is a structured method for documenting patient information in medical settings. It stands for Subjective, Objective, Assessment, and Plan. In poisoning cases, timely and accurate documentation using this format can be vital for patient care, legal clarity, and medical review. Below is a comprehensive example of a SOAP note tailored for a poisoning case SOAP note example poisoning case, specifically designed to provide insights into how healthcare professionals might record and manage such an incident efficiently.
Subjective
The patient is a 28-year-old female who presented to the emergency department complaining of dizziness, nausea, and abdominal pain. She reports ingesting an unknown quantity of household bleach approximately one hour prior to arrival in a self-harm attempt following a domestic argument. The patient admits to feeling regretful and states she did not intend to cause permanent harm. She denies any history of similar incidents or psychiatric diagnoses but mentions frequent anxiety episodes. No prior history of drug or alcohol use was disclosed. The patient states she began vomiting within 20 minutes of ingestion and experienced a burning sensation in her throat and chest.
Objective
On examination, the patient appears alert but visibly distressed. Vital signs are as follows: blood pressure 110/70 mmHg, heart rate 98 bpm, respiratory rate 22 breaths per minute, temperature 99.2°F, oxygen saturation 97% on room air. She has mild perioral erythema and halitosis suggestive of chemical ingestion. The abdominal examination reveals mild epigastric tenderness with no rebound or guarding. Cardiovascular and respiratory examinations are within normal limits. No signs of respiratory distress or cyanosis noted. Neurological exam shows the patient is oriented to time, place, and person.
Initial labs indicate leukocytosis with a WBC count of 14,000/mm³. Electrolytes are within normal range. Arterial blood gas (ABG) reveals mild metabolic acidosis. Chest and abdominal X-rays are unremarkable. Toxicology screen is pending. No signs of esophageal perforation are visible in imaging at this time.
Assessment
Acute bleach ingestion with gastrointestinal irritation and possible mild esophageal injury. The patient is currently stable but at risk for complications including chemical burns to mucosal linings, metabolic disturbances, or delayed-onset respiratory distress. The primary concern is corrosive injury to the upper GI tract and airway compromise. Her psychiatric state also requires assessment given the intentional nature of the ingestion.
Differential diagnoses include caustic esophagitis, chemical pneumonitis (if aspiration occurred), and stress-related gastritis. Her presentation does not suggest systemic toxicity or multi-organ dysfunction at this stage.
Plan
- Admit the patient to the medical observation unit for at least 24-hour monitoring.
- Initiate IV fluid therapy with normal saline to maintain hydration and correct any potential electrolyte imbalance.
- Consult gastroenterology for potential endoscopy within 12–24 hours to assess esophageal and gastric mucosa damage.
- Keep the patient nil per os (NPO) until further evaluation by GI.
- Administer proton pump inhibitor IV to reduce gastric acid secretion and protect mucosal lining.
- Pain management with acetaminophen as needed, avoiding NSAIDs due to potential mucosal injury.
- Monitor for signs of perforation, infection, or stridor. Repeat ABG if respiratory symptoms develop.
- Order toxicology panel and monitor renal and liver function daily.
- Psychiatric evaluation to be conducted as soon as the patient is stable to assess suicide risk and initiate appropriate therapy.
- Engage social services to provide support and evaluate the patient’s home environment before discharge.
Follow-Up Considerations
Depending on the outcome of the endoscopy and psychiatric assessment, the patient may be discharged with a follow-up appointment or transferred to a behavioral health facility. Education regarding the dangers of chemical ingestion and coping mechanisms for psychological stress will be provided upon discharge.
This SOAP note example for a poisoning case emphasizes the critical need for organized documentation in managing toxic exposure cases. It ensures that every domain of the patient’s condition—from physical symptoms to emotional triggers—is assessed and addressed in a standardized and efficient manner. Healthcare teams benefit from this structured approach by maintaining continuity of care and preparing for any evolving complications.
