Discussion: Areas of weakness
Discussion: Areas of weakness
Discussion: Areas of weakness
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. Submission Details: 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. Name: Pt. Encounter Number: Date: Age: Sex: SUBJECTIVE CC: Reason given by the patient for seeking medical care “in quotes” HPI: 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 ) PMH Allergies: Medication Intolerances: Chronic Illnesses/Major traumas Hospitalizations/Surgeries “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?” Family History 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? Social History Education level, occupational history, current living situation/partner/marital status, substance use/abuse, ETOH, tobacco, and marijuana. Safety status ROS General Weight change, fatigue, fever, chills, night sweats, and energy level Cardiovascular Chest pain, palpitations, PND, orthopnea, and edema Skin Delayed healing, rashes, bruising, bleeding or skin discolorations, and any changes in lesions or moles Respiratory Cough, wheezing, hemoptysis, dyspnea, pneumonia hx, and TB Eyes Corrective lenses, blurring, and visual changes of any kind Gastrointestinal Abdominal pain, N/V/D, constipation, hepatitis, hemorrhoids, eating disorders, ulcers, and black, tarry stools Ears Ear pain, hearing loss, ringing in ears, and discharge Genitourinary/Gynecological 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 Nose/Mouth/Throat Sinus problems, dysphagia, nose bleeds or discharge, dental disease, hoarseness, and throat pain Musculoskeletal Back pain, joint swelling, stiffness or pain, fracture hx, and osteoporosis Breast SBE, lumps, bumps, or changes Neurological Syncope, seizures, transient paralysis, weakness, paresthesias, and black-out spells Heme/Lymph/Endo HIV status, bruising, blood transfusion hx, night sweats, swollen glands, increase thirst, increase hunger, and cold or heat intolerance Psychiatric Depression, anxiety, sleeping difficulties, suicidal ideation/attempts, and previous dx OBJECTIVE Weight BMI Temp BP Height