Week 3 – Assignment 1 Discussion
Assignment 1: SOAP Note
Each week, you are required to enter your patient encounters into eMedley. Your faculty will be checking to ensure you are seeing the right number and mix of patients for a good learning experience. You will also need to include a minimum of one complete SOAP note using the SOAP Note template.
SOAP Note: Choose one patient from an area of weakness identified from the Week 1 Pre-Predictor Exam and submit a SOAP note of this patient. Remember to remove all forms of patient identification from the SOAP note format. Provide a reference (s) for the differential diagnosis and treatment plan in APA format. The reference should be within a 3-5 year time frame and come from a textbook, guideline, or currently published peer reviewed journal article.
By Wednesday, October 25, 2017, enter your patient encounters into eMedley and complete at least one SOAP note in the template provided.
Include the reference number from eMedley in your document.
Submit your SOAP note into the discussion area below by Sunday, October 22, 2017 along with clinical insights about your case.
Respond to two peers with a substantial response that includes supportive references by Wednesday, October 25, 2017.
Pt. Encounter Number:
Reason given by the patient for seeking medical care “in quotes”
Describe the course of the patient’s illness, including when it began, character of symptoms, location where the symptoms began, aggravating or alleviating factors, pertinent positives and negatives, other related diseases, past illnesses, and surgeries or past diagnostic testing related to the present illness.
Medications: (List with reason for med )
Chronic Illnesses/Major traumas
“Have you ever been told that you have diabetes, HTN, peptic ulcer disease, asthma, lung disease, heart disease, cancer, TB, thyroid problems, kidney problems, or psychiatric diagnosis?”
Does your mother, father, or siblings have any medical or psychiatric illnesses? Is anyone diagnosed with: lung disease, heart disease, HTN, cancer, TB, DM, or kidney disease?
Education level, occupational history, current living situation/partner/marital status, substance use/abuse, ETOH, tobacco, and marijuana. Safety status
Weight change, fatigue, fever, chills, night sweats, and energy level
Chest pain, palpitations, PND, orthopnea, and edema
Delayed healing, rashes, bruising, bleeding or skin discolorations, and any changes in lesions or moles
Cough, wheezing, hemoptysis, dyspnea, pneumonia hx, and TB
Corrective lenses, blurring, and visual changes of any kind
Abdominal pain, N/V/D, constipation, hepatitis, hemorrhoids, eating disorders, ulcers, and black, tarry stools
Ear pain, hearing loss, ringing in ears, and discharge
Urgency, frequency burning, change in color of urine.
Contraception, sexual activity, STDs
Female: last pap, breast, mammo, menstrual complaints, vaginal discharge, pregnancy hx
Male: prostate, PSA, urinary complaints
Sinus problems, dysphagia, nose bleeds or discharge, dental disease, hoarseness, and throat pain
Back pain, joint swelling, stiffness or pain, fracture hx, and osteoporosis
SBE, lumps, bumps, or changes
Syncope, seizures, transient paralysis, weakness, paresthesias, and black-out spells
HIV status, bruising, blood transfusion hx, night sweats, swollen glands, increase thirst, increase hunger, and cold or heat intolerance
Depression, anxiety, sleeping difficulties, suicidal ideation/attempts, and previous dx
Healthy-appearing adult female in no acute distress. Alert and oriented; answers questions appropriately. Slightly somber affect at first and then brighter later.
Skin is brown, warm, dry, clean, and intact. No rashes or lesions noted.
Head is normocephalic, atraumatic, and without lesions; hair evenly distributed. Eyes: PERRLA. EOMs intact. No conjunctival or scleral injection. Ears: Canals patent. Bilateral TMs pearly gray with positive light reflex; landmarks easily visualized. Nose: Nasal mucosa pink; normal turbinates. No septal deviation. Neck: Supple. Full ROM; no cervical lymphadenopathy; no occipital nodes. No thyromegaly or nodules. Oral mucosa, pink and moist. Pharynx is nonerythematous and without exudate. Teeth are in good repair.
S1, S2 with regular rate and rhythm. No extra sounds, clicks, rubs, or murmurs. Capillary refills two seconds. Pulses 3+ throughout. No edema.
Symmetric chest wall. Respirations regular and easy; lungs clear to auscultation bilaterally.
Abdomen obese; BS active in all the four quadrants. Abdomen soft, nontender. No hepatosplenomegaly.
Breast is free from masses or tenderness, no discharge, no dimpling, wrinkling, or discoloration of the skin.
Bladder is nondistended; no CVA tenderness. External genitalia reveals coarse pubic hair in normal distribution; skin color is consistent with general pigmentation. No vulvar lesions noted. Well estrogenized. A small speculum was inserted; vaginal walls are pink and well rugated; no lesions noted. Cervix is pink and nulliparous. Scant clear to cloudy drainage present. On bimanual exam, cervix is firm. No CMT. Uterus is antevert and positioned behind a slightly distended bladder; no fullness, masses, or tenderness. No adnexal masses or tenderness. Ovaries are nonpalpable.
(Male: Both testes are palpable, no masses or lesions, no hernia, and no uretheral discharge.)
(Rectal as appropriate: No evidence of hemorrhoids, fissures, bleeding, or masses—Males: Prostrate is smooth, nontender, and free from nodules, is of normal size, and sphincter tone is firm).
Full ROM seen in all four extremities as the patient moved about the exam room.
Speech clear. Good tone. Posture erect. Balance stable; gait normal.
Alert and oriented. Dressed in clean slacks, shirt, and coat. Maintains eye contact. Speech is soft, though clear and of normal rate and cadence; answers questions appropriately.
Include at least three differential diagnosis
Evidence for final diagnosis should be documented in your Subjective and Objective exams.
PLAN including education
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