Assignment_2 – SOAP
Students charge column one absorbing case that he/she has apparent in the analytic ambience via Discussion Board in the online allotment of this course. The case should be an abnormal diagnosis, or a circuitous case that appropriate all-embracing appraisal on the student’s part. The case should be acquaint in the SOAP format, with references for the accommodating diagnosis, cogwheel diagnoses (there should be at atomic 3), and the analysis plan. Addendum will be graded as "pass/fail". In adjustment to accept brand credibility for SOAP notes, the addendum charge be accustomed by the deadlines defined on the advance assignments page. The apprentice will lose the befalling for credibility on any SOAP addendum not accustomed by the defined deadlines. The announcement does not accept to be accounting in APA format, but should be accounting with actual spelling and grammar. References should be in APA format. The called references should reflect accepted affirmation – anachronous aural the accomplished 5 years.
Sample of a SOAP agenda below:
Patient is a 78-year-old man who alive assert that use sunblock he walks a lot outdoors and has a actual cogent and on his accoutrements with a boredom and accoutrements also.
He presented with cough. chest. The evidence started few canicule ago. It is declared as intermittent. Frequency is daily. The complaint is ongoing. Smoking status: Never smoker
Alcohol consumption: Never consumed
Substance abuse: Never consumed
Atenolol (25.00000 - mg), booty 1.00 book by aperture already a day
Lovastatin (40.00000 - mg), booty 1.00 book by aperture already a day
Pantoprazole sodium (40.00000 - mg), for 90 days,
Tramadol hcl (50.00000 - mg), booty 1.00 book by aperture alert a day
Allergies: He has no alive accepted allergies.
Review of History:
Arthrocentesis, aspiration and/or injection, above collective or atrium (eg, shoulder, hip, knee, subacromial bursa); after ultrasound guidance, Last performed on 10/02/2013.
Injection action for sacroiliac joint, anesthetic/steroid, with angel advice (fluoroscopy or ct) including arthrography back performed. Colonoscopy, flexible; with biopsy, distinct or assorted Last performed on 10/20/2010.
Complex uroflowmetry (eg, calibrated cyberbanking equipment), Last recorded on 08/26/2010.
Voiding burden studies (vp); float abolishment pressure, any technique. Measurement of post-voiding balance urine and/or float accommodation by ultrasound, non-imaging, Last recorded on 08/26/2010.
Cystourethroscopy (separate procedure), Last performed on 08/03/2017.
Biopsy, prostate; aggravate or punch, distinct or multiple, Last recorded on 07/02/2014.
Injection, analgesic abettor and/or steroid, paravertebral angle collective or angle collective nerve; lumbar or sacral, distinct level.
Injection, analgesic abettor and/or steroid, paravertebral angle collective or angle collective nerve; lumbar or sacral, anniversary added akin (list alone in accession to cipher for primary procedure).
Extracapsular avalanche abatement with admittance of intraocular lens prosthesis (1 date procedure), chiral or automated address (eg, irrigation and aspiration or phacoemulsification).
Reviewed the afterward accomplished medical:
Essential (primary) hypertension.
Gastro-esophageal abatement ache after esophagitis.
Benign prostatic hyperplasia after lower urinary amplitude symptoms. Barrett's esophagus after dysplasia.
Elevated prostate specific antigen [psa].
Benign prostatic hyperplasia with lower urinary amplitude symptoms.
Ventral breach after obstruction or gangrene.
He is married, never smoker, has never captivated alcohol, is a accepted every day customer of coffee or tea, is not a actuality abuser, has a Dairy Free diet, follows a counterbalanced diet, has acceptable blow or recreation, does not accept a chancy animal behavior, does not accept disabilities, does not accept ancestors stress, does not accept job stress, does not do concrete exercise,has active arrangements: Private Residence with Family.
Family History: His ancestors presents the afterward diseases: his Mother has Affection ache (high claret pressure), his Father has Affection ache (heart).
Eyes: The accommodating denied change in vision, eye pain, redness, discharge.
Ears, Nose, Mouth, Throat (ENT): The accommodating denied accident hearing, congestion, atrium pain, change in hearing, campanology in aerial (tinnitus), common adenoids bleeds (epistaxi), abscessed throat, hoarseness, ear pain, affliction in throat.
Respiratory: The accommodating complained of cough, but denied wheezing, hemoptysis, phlegm.
Cardiovascular: The accommodating denied chest pain, palpitations, dyspnea, orthopnea, conciseness of breath, hypertension.
Gastrointestinal: The accommodating denied acidity, gastritis, flatulence, hiccups, belly pain, adversity swallowing(solids vs liquids), bloating, nausea, diarrhea, constipation, ablaze red claret per rectum (BRBPR,hematochezia), vomiting_, change in bowel habits, hemorrhoids. GU/Gyne/0B: The accommodating denied dysuria, hematuria, incontinence, affliction with urination, blurred urine, abdominal discomfort.
Musculoskeletal: The accommodating complained of pain. Left Hip Pain, but denied wound, abscess (edema), tenderness, weakness, areas of numbness. Neurological: The accommodating denied dizziness, faints, headache, numbness, limb weakness, tremor, anamnesis loss.
Psychiatric: The accommodating denied depression, anxiety, insomnia, baleful thoughts.
Endocrine: The accommodating denied - diabetes mellitus, beard loss, calefaction or algid intolerance, change in facial or anatomy hair, cf\ange in weight. lnteg.urnentary (skin and/or breast): The accommodating denied itching, change in moles, dry skin, ecchymosis, onychomycosis, lesion, abscess, rash. Hematologic/Lymphatic: The accommodating denied anemia, accessible bruising, breakable or apparent lymph nodes.
Allergic/Immunologic: The accommodating denied alternative reactions, sneezing, aqueous nose, column nasal drip.
Constitutional: The accommodating denied fever, weight loss, weight gain, night sweats, fatigue/malaise/lethargy.
Vital Signs: Weight: 176 lb O oz. Height: 5 ft 8 in.
Pulse: 64 bpm. Pulse: Normal, interpretation: Normal
Blood Pressure: 140/70 mmHg. Location: Left Arm. Position: Sitting. Temperature: 97.6 degrees F. BMI: 26.8 kg/m2. Respiratory rate: 16 bpm.
PE: Constitutional: Overall: Alert, cooperative.in no distress.appears declared age. Development: able-bodied developed. Nourishment: able-bodied nourished. Eyes: Eye: Conjunctivae and sclerae are bright after icterus.Pupils are acknowledging and equal..
Ears, Nose, Mouth, Throat (ENT}: Head: Normocephalic, after accessible abnormality,atraumatic .. Ears: Accustomed alien ear canals, both aerial .. Nose: film accustomed no drainage.bleeding .. Throat: Lips film , and argot normal; teeth and gums normal. Neck: Supple,Symmetrical,trachea midline,no adenopathy,no carotid bruit or JVD. Thyroid gland: normal. Mouth: Lips film , and argot normal; teeth and gums normal. Cardiovascular: Pulse: regular. Claret pressure: normal. Auscultation: murmur. I/VI SEM.
Respiratory: Chest and Lungs: Bright to ascultation bilaterally, respiration unlabored,no wheezing, rales or crackles ..
Gastrointestinal: Abdomen: hernia. Huge midline breach Stable. Rectal: deferred. GU/Gyne/OB: Genitalia: deferred.
Musculoskeletal: Hip: pain. Left Hip affliction in calibration 1 -10 letters 7. Upper extremities: accustomed atraumatic, no cyanosis or edema. Lower extremities: accustomed atraumatic, no cyanosis or edema.
lntegumentary (skin and/or breast): Skin: Bark color,texture,turgor normal.no rashes,or lesions .. Nails: normal.
Neurological: Cranial nerves: Cranial Nerves II-XII appears intact. Motor: normal. Coordination and Gait: Alert,Oriented. Reflexes: Strength normal. Sensory: Alert.Oriented,
Psychiatric: Orientation to time, abode and person: normal. Recent and alien memory: normal. Affection and affect: No distress,mood looks normal,no agitation,no hallucinations.
Hematologic/Lymphatic: Groin: normal. Other: Cervical, supraclavicular and axillary nodes normal.
Chest / Breast: Breasts: normal.
Essential (primary) hypertension.
Body accumulation basis (bmi) 26.0-26.9, adult.
Follow up on 1 month
Kenalog 40 mg IM,
Zithromax Z Pack
Cholesterol diet - acutely black fruits and vegetables, cilia affluent atom products, fat-free products, 1 percent and low fat milk products, angular meats and banty after skin, blubbery fish, nuts, seeds, an legumes(dried beans or peas), and unsaturated vegetable oils ..
Patient Education: She accustomed exact educational instructions for All the questions was answered and understood, breast cocky exam, Call or Return if Affection aggravate or persist, Abasement Screening Performed today, Discussed Bowel and Float Control, Fall precautions and Accident prevention, I Discussed all analysis options with the patient, Reviewed all Accepted Medications, bench belt, Bark protection, stress
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