Expert Homework Help Online & Write My Essay Service

Hire best homework helpers for online homework help 24/7. Are you looking for online homework help? Try our excellent homework help who can help you get A+ grade in your assignment.

Order my paper
Calculate your essay price
(550 words)

Approximate price: $22

19 k happy customers
9.5 out of 10 satisfaction rate
527 writers active

Soap Note 1 Acute Conditions Assignment

Soap Note 1 Acute Conditions AssignmentSoap Note 1 Acute Conditions AssignmentPick any Acute Disease: Use Guillain-Barré syndromeMust use the sample template for your soap note.Follow the Soap Note Rubric as a guideUse APA format and must include minimum of 2 Scholarly Citations.Soap notes will be uploaded to Moodle and put through TURN-It-In (anti-Plagiarism program)Copy paste from websites or textbooks will not be accepted or tolerated.The use of templates is ok, but the Patient History, CC, HPI, The Assessment and Plan should be of your own work and individualized to your made up patient.Grading RubricStudent______________________________________This sheet is to help you understand what we are looking for, and what our margin remarks might be about on your write ups of patients. Since at all of the white-ups that you hand in are uniform, this represents what MUST be included in every write-up.Soap Note 1 Acute Conditions AssignmentORDER A PLAGIARISM-FREE PAPER HERE1) Identifying Data (___5pts): The opening list of the note. It contains age, sex, race, marital status, etc. The patient complaint should be given in quotes. If the patient has more than one complaint, each complaint should be listed separately (1, 2, etc.) and each addressed in the subjective and under the appropriate number. 2) Subjective Data (___30pts.): This is the historical part of the note. It contains the following: a) Symptom analysis/HPI(Location, quality , quantity or severity, timing, setting, factors that make it better or worse, and associate manifestations.(10pts).b) Review of systems of associated systems, reporting all pertinent positives and negatives (10pts).c) Any PMH, family hx, social hx, allergies, medications related to the complaint/problem (10pts). If more than one chief complaint, each should be written u in this manner. 3) Objective Data(__25pt.): Vital signs need to be present. Height and Weight should be included where appropriate. a) Appropriate systems are examined, listed in the note and consistent with those identified in 2b.(10pts).b) Pertinent positives and negatives must be documented for each relevant system.c) Any abnormalities must be fully described. Measure and record sizes of things (likes moles, scars). Avoid using “ok”, “clear”, “within normal limits”, positive/ negative, and normal/abnormal to describe things. (5pts).Soap Note 1 Acute Conditions Assignment4) Assessment (___10pts.): Diagnoses should be clearly listed and worded appropriately. 5) Plan (___15pts.): Be sure to include any teaching, health maintenance and counseling along with the pharmacological and non-pharmacological measures. If you have more than one diagnosis, it is helpful to have this section divided into separate numbered sections. 6) Subjective/ Objective, Assessment and Management and Consistent (___10pts.): Does the note support the appropriate differential diagnosis process? Is there evidence that you know what systems and what symptoms go with which complaints? The assessment/diagnoses should be consistent with the subjective section and then the assessment and plan. The management should be consistent with the assessment/ diagnoses identified. 7) Clarity of the Write-up(___5pts.): Is it literate, organized and complete? Comments: Total Score: ____________ Instructor: __________________________________      Guidelines for Focused SOAP Notes· Label each section of the SOAP note (each body part and system).· Do not use unnecessary words or complete sentences.· Use Standard AbbreviationsS: SUBJECTIVE DATA (information the patient/caregiver tells you).Chief Complaint (CC): a statement describing the patient’s symptoms, problems, condition, diagnosis, physician-recommended return(s) for this patient visit. The patient’s own words should be in quotes.Soap Note 1 Acute Conditions AssignmentHistory of present illness (HPI): a chronological description of the development of the patient’s chief complaint from the first symptom or from the previous encounter to the present. Include the eight variables (Onset, Location, Duration, Characteristics, Aggravating Factors, Relieving Factors, Treatment, Severity-OLDCARTS), or an update on health status since the last patient encounter.Past Medical History (PMH): Update current medications, allergies, prior illnesses and injuries, operations and hospitalizations allergies, age-appropriate immunization status.Family History (FH): Update significant medical information about the patient’s family (parents, siblings, and children). Include specific diseases related to problems identified in CC, HPI or ROS.Social History(SH): An age-appropriate review of significant activities that may include information such as marital status, living arrangements, occupation, history of use of drugs, alcohol or tobacco, extent of education and sexual history.Review of Systems (ROS). There are 14 systems for review. List positive findings and pertinent negatives in systems directly related to the systems identified in the CC and symptoms which have occurred since last visit; (1) constitutional symptoms (e.g., fever, weight loss), (2) eyes, (3) ears, nose, mouth and throat, (4) cardiovascular, (5) respiratory, (6) gastrointestinal, (7) genitourinary, (8) musculoskeletal, (9-}.integument (skin and/or breast), (10) neurological, (11) psychiatric, (12) endocrine, (13) hematological/lymphatic, {14) allergic/immunologic. The ROS should mirror the PE findings section.0: OBJECTIVE DATA (information you observe, assessment findings, lab results).Sufficient physical exam should be performed to evaluate areas suggested by the history and patient’s progress since last visit. Document specific abnormal and relevant negative findings. Abnormal or unexpected findings should be described. You should include only the information which was provided in the case study, do not include additional data.Soap Note 1 Acute Conditions AssignmentRecord observations for the following systems if applicable to this patient encounter (there are 12 possible systems for examination): Constitutional (e.g. vita! signs, general appearance), Eyes, ENT/mouth, Cardiovascular, Respiratory, GI, GU, Musculoskeletal, Skin, Neurological, Psychiatric, Hematological/lymphatic/immunologic/lab testing. The focused PE should only include systems for which you have been given data.NOTE: Cardiovascular and Respiratory systems should be assessed on every patient regardless of the chief complaint.Testing Results: Results of any diagnostic or lab testing ordered during that patient visit.A: ASSESSMENT: (this is your diagnosis (es) with the appropriate ICD 10 code)List and number the possible diagnoses (problems) you have identified. These diagnoses are the conclusions you have drawn from the subjective and objective data.Remember: Your subjective and objective data should support your diagnoses and your therapeutic plan.Do not write that a diagnosis is to be “ruled out” rather state the working definitions of each differential or primary diagnosis (es).For each diagnoses provide a cited rationale for choosing this diagnosis. This rationale includes a one sentence cited definition of the diagnosis (es) the pathophysiology, the common signs and symptoms, the patients presenting signs and symptoms and the focused PE findings and tests results that support the dx. Include the interpretation of all lab data given in the case study and explain how those results support your chosen diagnosis.P: PLAN (this is your treatment plan specific to this patient). Each step of your plan must include an EBP citation.1. Medications write out the prescription including dispensing information and provide EBP to support ordering each medication. Be sure to include both prescription and OTC medications.Soap Note 1 Acute Conditions Assignment2. Additional diagnostic tests include EBP citations to support ordering additional tests3. Education this is part of the chart and should be brief, this is not a patient education sheet and needs to have a reference.4. Referrals include citations to support a referral5. Follow up. Patient follow-up should be specified with time or circumstances of return. You must provide a reference for your decision on when to follow up.(Student Name)Miami Regional UniversityDate of Encounter:Preceptor/Clinical Site:Clinical Instructor: Dr. David Trabanco DNP, APRN, AGNP-C, FNP-CSoap Note 1 Acute Conditions AssignmentSoap Note # Main Diagnosis ( Exp: Soap Note #3 DX: Hypertension)Soap Note 1 Acute Conditions AssignmentPATIENT INFORMATIONName: Mr. DTAge: 68-year-oldGender at Birth: MaleGender Identity: MaleSource: PatientAllergies: PCN, IodineCurrent Medications:· Atorvastatin tab 20 mg, 1-tab PO at bedtime· ASA 81mg po daily· Multi-Vitamin Centrum SilverPMH: HypercholesterolemiaImmunizations: Influenza last 2018-year, tetanus, and hepatitis A and B 4 years ago.Preventive Care: Coloscopy 5 years ago (Negative)Surgical History: Appendectomy 47 years ago.Family History: Father- died 81 does not report informationMother-alive, 88 years old, Diabetes Mellitus, HTNDaughter-alive, 34 years old, healthySocial History: No smoking history or illicit drug use, occasional alcoholic beverage consumption on social celebrations. Retired, widow, he lives alone.Sexual Orientation: StraightNutrition History: Diets off and on, Does not each seafoodSubjective Data:Soap Note 1 Acute Conditions AssignmentChief Complaint: “headaches” that started two weeks agoSymptom analysis/HPI:The patient is 65 years old male who complaining of episodes of headaches and on 3 different occasions blood pressure was measured, which was high (159/100, 158/98 and 160/100 respectively). Patient noticed the problem started two weeks ago and sometimes it is accompanied by dizziness. He states that he has been under stress in his workplace for the last month. Patient denies chest pain, palpitation, shortness of breath, nausea or vomiting.Soap Note 1 Acute Conditions AssignmentReview of Systems (ROS)CONSTITUTIONAL: Denies fever or chills. Denies weakness or weight loss. NEUROLOGIC: Headache and dizziness as describe above. Denies changes in LOC. Denies history of tremors or seizures.HEENT: HEAD: Denies any head injury, or change in LOC. Eyes: Denies any changes in vision, diplopia or blurred vision. Ear: Denies pain in the ears. Denies loss of hearing or drainage. Nose: Denies nasal drainage, congestion. THROAT: Denies throat or neck pain, hoarseness, difficulty swallowing.RESPIRATORY: Patient denies shortness of breath, cough or hemoptysis.CARDIOVASCULAR: No chest pain, tachycardia. No orthopnea or paroxysmal nocturnaldyspnea.GASTROINTESTINAL: Denies abdominal pain or discomfort. Denies flatulence, nausea, vomiting ordiarrhea.GENITOURINARY: Denies hematuria, dysuria or change in urinary frequency. Denies difficulty starting/stopping stream of urine or incontinence.MUSCULOSKELETAL: Denies falls or pain. Denies hearing a clicking or snapping sound.SKIN: No change of coloration such as cyanosis or jaundice, no rashes or pruritus. Objective Data:VITAL SIGNS: Temperature: 98.5 °F, Pulse: 87, BP: 159/92 mmhg, RR 20, PO2-98% on room air, Ht- 6’4”, Wt 200 lb, BMI 25. Report pain 2/10.Soap Note 1 Acute Conditions AssignmentGENERAL APPREARANCE: The patient is alert and oriented x 3. No acute distress noted. NEUROLOGIC: Alert, CNII-XII grossly intact, oriented to person, place, and time. Sensation intact to bilateral upper and lower extremities. Bilateral UE/LE strength 5/5.Soap Note 1 Acute Conditions AssignmentHEENT: Head: Normocephalic, atraumatic, symmetric, non-tender. Maxillary sinuses no tenderness. Eyes: No conjunctival injection, no icterus, visual acuity and extraocular eye movements intact. No nystagmus noted. Ears: Bilateral canals patent without erythema, edema, or exudate. Bilateral tympanic membranes intact, pearly gray with sharp cone of light. Maxillary sinuses no tenderness. Nasal mucosa moist without bleeding. Oral mucosa moist without lesions,. Lids non-remarkable and appropriate for race. Neck: supple without cervical lymphadenopathy, no jugular vein distention, no thyroid swelling or masses.CARDIOVASCULAR: S1S2, regular rate and rhythm, no murmur or gallop noted. Capillary refill < 2 sec.RESPIRATORY: No dyspnea or use of accessory muscles observed. No egophony, whispered pectoriloquy or tactile fremitus on palpation. Breath sounds presents and clear bilaterally on auscultation.GASTROINTESTINAL: No mass or hernia observed. Upon auscultation, bowel sounds present in all four quadrants, no bruits over renal and aorta arteries. Abdomen soft non-tender, no guarding, no rebound no distention or organomegaly noted on palpationMUSKULOSKELETAL: No pain to palpation. Active and passive ROM within normal limits, no stiffness.INTEGUMENTARY: intact, no lesions or rashes, no cyanosis or jaundice.Soap Note 1 Acute Conditions AssignmentASSESSMENT:Main DiagnosisEssential (Primary) Hypertension (ICD10 I10): Given the symptoms and high blood pressure (156/92 mmhg), classified as stage 2. Once the organic cause of hypertension has been ruled out, such as renal, adrenal or thyroid, this diagnosis is confirmed (Codina Leik, 2015). Diagnosis is based on the clinical evaluation through history, physical examination, and routine laboratory tests to assess risk factors, reveal identifiable causes and detect target-organ damage, including evidence of cardiovascular disease (Domino et al,. 2017).Soap Note 1 Acute Conditions AssignmentDifferential diagnosis:· Renal artery stenosis (ICD10 I70.1)· Chronic kidney disease (ICD10 I12.9)· Hyperthyroidism (ICD10 E05.90)PLAN: Labs and Diagnostic Test to be ordered:· CMP· Complete blood count (CBC)· Lipid profile· Thyroid-stimulating hormone (TSH)· Urinalysis with Micro· Electrocardiogram (EKG 12 lead) Pharmacological treatment:· Hydrochlorothiazide tab 25 mg, Initial dose: 25 mg orally once daily.· Lisinopril 10mg PO DailySoap Note 1 Acute Conditions AssignmentNon-Pharmacologic treatment:· Weight loss· Healthy diet (DASH dietary pattern): Diet rich in fruits, vegetables, whole grains, and low-fat dairy products with reduced content of saturated and trans l fat· Reduced intake of dietary sodium: <1,500 mg/d is optimal goal but at least 1,000 mg/d reduction in most adults· Enhanced intake of dietary potassium· Regular physical activity (Aerobic): 90–150 min/wk· Tobacco cessation· Measures to release stress and effective coping mechanisms.Education· Provide with nutrition/dietary information.Soap Note 1 Acute Conditions Assignment· Daily blood pressure monitoring log at home twice a day for 7 days, keep a record, bring the record on the next visit with her PCP· Instruction about medication intake compliance.· Education of possible complications such as stroke, heart attack, and other problems.· Patient was educated on course of hypertension, as well as warning signs and symptoms, which could indicate the need to attend the E.R/U.C. Answered all pt. questions/concerns. Pt verbalizes understanding to allFollow-ups/Referrals· Follow up appointment 1 weeks for managing blood pressure and to evaluate current hypotensive therapy.· No referrals needed at this time.Soap Note 1 Acute Conditions AssignmentReferencesCodina Leik, M. T. (2014). Family Nurse Practitioner Certification Intensive Review (2nd ed.).ISBN 978-0-8261-3424-0Domino, F., Baldor, R., Golding, J., Stephens, M. (2017). The 5-Minute Clinical Consult 2017(25th ed.). Print (The 5-Minute Consult Series). Soap Note 1 Acute Conditions Assignment

Place your order
(550 words)

Approximate price: $22

Calculate the price of your order

550 words
We'll send you the first draft for approval by September 11, 2018 at 10:52 AM
Total price:
$26
The price is based on these factors:
Academic level
Number of pages
Urgency
Basic features
  • Free title page and bibliography
  • Unlimited revisions
  • Plagiarism-free guarantee
  • Money-back guarantee
  • 24/7 support
On-demand options
  • Writer’s samples
  • Part-by-part delivery
  • Overnight delivery
  • Copies of used sources
  • Expert Proofreading
Paper format
  • 275 words per page
  • 12 pt Arial/Times New Roman
  • Double line spacing
  • Any citation style (APA, MLA, Chicago/Turabian, Harvard)

Our guarantees

Money-back guarantee

You have to be 100% sure of the quality of your product to give a money-back guarantee. This describes us perfectly. Make sure that this guarantee is totally transparent.

Read more

Zero-plagiarism guarantee

Each paper is composed from scratch, according to your instructions. It is then checked by our plagiarism-detection software. There is no gap where plagiarism could squeeze in.

Read more

Free-revision policy

Thanks to our free revisions, there is no way for you to be unsatisfied. We will work on your paper until you are completely happy with the result.

Read more

Privacy policy

Your email is safe, as we store it according to international data protection rules. Your bank details are secure, as we use only reliable payment systems.

Read more

Fair-cooperation guarantee

By sending us your money, you buy the service we provide. Check out our terms and conditions if you prefer business talks to be laid out in official language.

Read more
error: