Posted: July 26th, 2016
SOAP note for case study 1 with at least 2 to 3 references not more than 3 years old. History / Subjective: Include ONLY significant positives & negatives from HPI, PMH, SH, FH & Review of Systems involved: PE Findings / Objective: Indicate ONLY the pertinent positive & negative findings related to the patientâs chief complaint: Assessment / Differential Diagnosis â Briefly support each Assessment based from S & O: Plan / Diagnostic Workup â Briefly support each. Contains a brief, concise & organized way to present a patientâs presenting problem, diagnosis & plan of management. It should be on SOAP format: 1. Subjective HxPI, PMHx, FHx, S/PHx â focused & significant data only ROS list pertinent (+) & () from history/patient interview in relation to the chief complaint. 2. Objective Ptâs biographics, vitals, pertinent (+) & () PE findings by observation & physical examination. Add any new hard data, such as laboratory results. 3. Assessment/Differential Diagnosis List of differential diagnosis in order of priority. All diagnosis should be supported by the data picked up from âSâ & âOâ Summarize all ongoing problems with the patient’s current status. 4. Plan Plan of management (diagnostic & treatment) with appropriate rationale. What you intend to do with the info obtained. Include supportive management, medications and medication changes, diagnostic/lab workup, referrals, recommendations, patient education and followup. Management plan appropriate for the diagnosis/problem identified should be economically sound & individualized. Competency: Demonstrates critical thinking, analysis, and ability to write at the graduate level. Critical thinking, analysis, and writing style are at the graduate level, free of all spelling, grammar, or punctuation errors. OUR COURSE BOOK ARE Physical Examination and Health Assessment, 6th Edition 6th Edition, PHARMACOTHERAPEUTICS FOR NURSE PRACTITIONER PRESCRIBERS3RD EDTION. HERE IS THE CASE; A 66 YEARNON ENGLISH SPEAKING WOMAN “HELEN” PRESENTED TO YOUR AMBULATORY CLINIC WITH A 1WEEK HISTORY IF GENERALIZED MALAISE, FEVER,HEADACHE, BACK PAIN,PRODUCTIVE COUGH WITH MINIMAL PURULENT SPUTUM, INCREASING SHORTNESS OF BREATH AND ABDOMINAL PAIN, SHE IS ACCOMPANIED BY HER 30YEAROLD DAUGHTER, WHO IS ABLE TO TRANSLATE. HELEN VISITED AN AMBULATORY CLINIC THREE DAYS AGO AND WAS PRESCRIBED AN ANTIBIOTICS BUT NOW SHE CLAIMS SHE’S IS ONLY GETTING WORSE. SHE HAS A HISTORY OF POORLY MANAGED TYPE 11 DIABETES, HYPERTENSION, HYPERLIPIDEMIA, AND OSTEOARTHRITIS OF HER KNEE FOR WHICH ACETAMINOPHEN AND DIFFERENT OTC NONSTEROIDAL ANTIINFLAMMATORY DRUGS. SHE IS OBESE, BUT HAS AN UNINTENTIONAL WEIGHT LOSS OF 8 ILBS OVER THE LAST PAST 6 WEEKS. SHE IS A SMOKIER WITH 40 PACK YEAR HISTORY. BOTH HER PARENTS HAVE PASSED AWAY BUT SHE CANNOT RECALL THEIR CAUSE OF DEATH; SISTER DIE OF “HEART ATTACK”, NO ANY OTHER SIGNIFICANT FAMILY HISTORY THAT SHE CAN THINK OF. GENERALLY SHE IS ALERT AND ORIENTED, BUT APPEARED TO BE IN MILD RESPIRATORY DISTRESS. BP=162/90; HR=88/MIN; RR=28/MIN; T=37.8C; 02 SAT=8990% ON AMBULATION; WT.=168 IBS.: HT.+5’2:REVIEW OF SYSTEM AS MENTIONED ABOVE. ABNORMAL PHYSICAL EXAMINATION FINDINGS INCLUDES BIBASILAR CRACKLES AND BILATERAL EXPIRATORY WHEEZES ON AUSCULTATION AND DULLNESS OVER THE RIGHT BASE ON PERCUSSION. NO USE OF ACCESSORY MUSCLES, NO NASAL FLARING. RIGHT SIDED CHEST PAIN IS PRESENT ON DEEP INSPIRATION AND COUGHING. BILATERAL ANTERIOR CERVICAL AND SUPRACLAVICULAR LYMPHADENOPATHY WERE PRESENT. ABDOMINAL PALPATION IS UNREMARKABLE. LIMB EXAMINATION FOUND 2+BILATERAL LOWER EXTREMITY EDEMA, BUT THERE WAS NO WARMTH, ERYTHEMA OR TENDERNESS. HOMAN’S SIGN WAS NEGATIVE. SHE SLEEPS SITTING ON THE COUGH TO EASE HER SHORTNESS OF BREATH. MARIA’S ELECTROCARDIOGRAM (ECG) IS WITHIN NORMAL LIMITS; NO OTHER DIAGNOSTIC RESULTS AVAILABLE. SHE WAS TREATED AT THE CLINIC WHERE WENT TO, EMPIRICALLY FOR PNEUMONIA AND HYPERTENSION. A FOLLOW UPUP VISIT WAS SCHEDULED AFTER 3 DAYS. THE INITIAL MEDICAL PLAN INCLUDED RESPIRATORY TREATMENTS, AZITHROMYCIN (ZPAK) AS DIRECTED, AND HYDROCHLOROTHIAZIDE (HCTZ) 25 MG TWO TIMES A DAY
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