Loading...

Messages

Proposals

Stuck in your homework and missing deadline? Get urgent help in $10/Page with 24 hours deadline

Get Urgent Writing Help In Your Essays, Assignments, Homeworks, Dissertation, Thesis Or Coursework & Achieve A+ Grades.

Privacy Guaranteed - 100% Plagiarism Free Writing - Free Turnitin Report - Professional And Experienced Writers - 24/7 Online Support

Episodic focused soap note format

04/01/2021 Client: saad24vbs Deadline: 3 days

CASE STUDY 2: Focused Throat Exam Lily is a 20-year-old student at the local community college. When some of her friends and classmates told her about an outbreak of flu-like symptoms sweeping her campus during the past 2 weeks, Lily figured she shouldn't take her 3-day sore throat lightly. Your clinic has treated a few cases similar to Lily's. All the patients reported decreased appetite, headaches, and pain with swallowing. As Lily recounts these symptoms to you, you notice that she has a runny nose and a slight hoarseness in her voice but doesn't sound congested.


To Prepare


· By Day 1 of this week, you will be assigned to a specific case study for this Case Study Assignment. Please see the “Course Announcements” section of the classroom for your assignment from your Instructor.


· Also, your Case Study Assignment should be in the Episodic/Focused SOAP Note format rather than the traditional narrative style format. Refer to Chapter 2 of the Sullivan text and the Episodic/Focused SOAP Template in the Week 5 Learning Resources for guidance. Remember that all Episodic/Focused SOAP Notes have specific data included in every patient case.


With regard to the case study you were assigned:


· Review this week's Learning Resources and consider the insights they provide.


· Consider what history would be necessary to collect from the patient.


· Consider what physical exams and diagnostic tests would be appropriate to gather more information about the patient's condition. How would the results be used to make a diagnosis?


· Identify at least five possible conditions that may be considered in a differential diagnosis for the patient.


The Assignment


Use the Episodic/Focused SOAP Template and create an episodic/focused note about the patient in the case study to which you were assigned using the episodic/focused note template provided in the Week 5 resources. Provide evidence from the literature to support diagnostic tests that would be appropriate for each case. List five different possible conditions for the patient's differential diagnosis and justify why you selected each.


Episodic/Focused SOAP Note Template – (delete information on this template and input one related to the patient in the case study above).


Patient Information:


Initials, Age, Sex, Race


S.


CC (chief complaint) a BRIEF statement identifying why the patient is here - in the patient’s own words - for instance "headache", NOT "bad headache for 3 days”.


HPI: This is the symptom analysis section of your note. Thorough documentation in this section is essential for patient care, coding, and billing analysis. Paint a picture of what is wrong with the patient. Use LOCATES Mnemonic to complete your HPI. You need to start EVERY HPI with age, race, and gender (e.g., 34-year-old AA male). You must include the seven attributes of each principal symptom in paragraph form not a list. If the CC was “headache”, the LOCATES for the HPI might look like the following example:


Location: head


Onset: 3 days ago


Character: pounding, pressure around the eyes and temples


Associated signs and symptoms: nausea, vomiting, photophobia, phonophobia


Timing: after being on the computer all day at work


Exacerbating/ relieving factors: light bothers eyes, Aleve makes it tolerable but not completely better


Severity: 7/10 pain scale


Current Medications: include dosage, frequency, length of time used and reason for use; also include OTC or homeopathic products.


Allergies: include medication, food, and environmental allergies separately (a description of what the allergy is ie angioedema, anaphylaxis, etc. This will help determine a true reaction vs intolerance).


PMHx: include immunization status (note date of last tetanus for all adults), past major illnesses and surgeries. Depending on the CC, more info is sometimes needed



Soc Hx: include occupation and major hobbies, family status, tobacco & alcohol use (previous and current use), any other pertinent data. Always add some health promo question here - such as whether they use seat belts all the time or whether they have working smoke detectors in the house, living environment, text/cell phone use while driving, and support system.


Fam Hx: illnesses with possible genetic predisposition, contagious or chronic illnesses. Reason for death of any deceased first degree relatives should be included. Include parents, grandparents, siblings, and children. Include grandchildren if pertinent.


ROS: cover all body systems that may help you include or rule out a differential diagnosis You should list each system as follows: General: Head: EENT: etc. You should list these in bullet format and document the systems in order from head to toe.


Example of Complete ROS:


GENERAL: No weight loss, fever, chills, weakness or fatigue.


HEENT: Eyes: No visual loss, blurred vision, double vision or yellow sclerae. Ears, Nose, Throat: No hearing loss, sneezing, congestion, runny nose or sore throat.


SKIN: No rash or itching.


CARDIOVASCULAR: No chest pain, chest pressure or chest discomfort. No palpitations or edema.


RESPIRATORY: No shortness of breath, cough or sputum.


GASTROINTESTINAL: No anorexia, nausea, vomiting or diarrhea. No abdominal pain or blood.


GENITOURINARY: Burning on urination. Pregnancy. Last menstrual period, MM/DD/YYYY.


NEUROLOGICAL: No headache, dizziness, syncope, paralysis, ataxia, numbness or tingling in the extremities. No change in bowel or bladder control.


MUSCULOSKELETAL: No muscle, back pain, joint pain or stiffness.


HEMATOLOGIC: No anemia, bleeding or bruising.


LYMPHATICS: No enlarged nodes. No history of splenectomy.


PSYCHIATRIC: No history of depression or anxiety.


ENDOCRINOLOGIC: No reports of sweating, cold or heat intolerance. No polyuria or polydipsia.


ALLERGIES: No history of asthma, hives, eczema or rhinitis.


O.


Physical exam: From head-to-toe, include what you see, hear, and feel when doing your physical exam. You only need to examine the systems that are pertinent to the CC, HPI, and History. Do not use “WNL” or “normal.” You must describe what you see. Always document in head to toe format i.e. General: Head: EENT: etc.


Diagnostic results: Include any labs, x-rays, or other diagnostics that are needed to develop the differential diagnoses (support with evidenced and guidelines)


A.


Differential Diagnoses (list a minimum of 3 differential diagnoses).Your primary or presumptive diagnosis should be at the top of the list. For each diagnosis, provide supportive documentation with evidence based guidelines.


P.


This section is not required for the assignments in this course (NURS 6512) but will be required for future courses.


References


You are required to include at least three evidence based peer-reviewed journal articles or evidenced based guidelines which relates to this case to support your diagnostics and differentials diagnoses. Be sure to use correct APA 6th edition formatting.


Resources for references


Ball, J. W., Dains, J. E., Flynn, J. A., Solomon, B. S., & Stewart, R. W. (2019). Seidel's guide to physical examination: An interprofessional approach (9th ed.). St. Louis, MO: Elsevier Mosby.


Chapter 11, “Head and Neck”


     This chapter reviews the anatomy and physiology of the head and neck. The authors also describe the procedures for conducting a physical examination of the head and neck.

Chapter 12, “Eyes”


     In this chapter, the authors describe the anatomy and function of the eyes. In addition, the authors explain the steps involved in conducting a physical examination of the eyes.

Chapter 13, “Ears, Nose, and Throat”


     The authors of this chapter detail the proper procedures for conducting a physical exam of the ears, nose, and throat. The chapter also provides pictures and descriptions of common abnormalities in the ears, nose, and throat.

Dains, J. E., Baumann, L. C., & Scheibel, P. (2019). Advanced health assessment and clinical diagnosis in primary care (6th ed.). St. Louis, MO: Elsevier Mosby.


Credit Line: Advanced Health Assessment and Clinical Diagnosis in Primary Care, 6th Edition by Dains, J.E., Baumann, L. C., & Scheibel, P. Copyright 2019 by Mosby. Reprinted by permission of Mosby via the Copyright Clearance Center.




Chapter 15, “Earache”

This chapter covers the main questions that need to be asked about the patient’s condition prior to the physical examination as well as how these questions lead to a focused physical examination.


Chapter 21, “Hoarseness”

This chapter focuses on the most common causes of hoarseness. It provides strategies for evaluating the patient, both through questions and through physical exams.


Chapter 25, “Nasal Symptoms and Sinus Congestion”


In this chapter, the authors highlight the key questions to ask about the patients symptoms, the key parts of the physical examination, and potential laboratory work that might be needed to provide an accurate diagnosis of nasal and sinus conditions.


Chapter 30, “Red Eye”


The focus of this chapter is on how to determine the cause of red eyes in a patient, including key symptoms to consider and possible diagnoses.


Chapter 32, “Sore Throat”


A sore throat is one most common concerns patients describe. This chapter includes questions to ask when taking the patient’s history, things to look for while conducting the physical exam, and possible causes for the sore throat.


Chapter 38, “Vision Loss”

This chapter highlights the causes of vision loss and how the causes of the condition can be diagnosed.


Ball, J. W., Dains, J. E., Flynn, J. A., Solomon, B. S., & Stewart, R. W. (2019). Head and neck: Student checklist. In Seidel's guide to physical examination: An interprofessional approach (9th ed.). St. Louis, MO: Elsevier Mosby.


Credit Line: Seidel's Guide to Physical Examination, 9th Edition by Ball, J. W., Dains, J. E., Flynn, J. A., Solomon, B. S., & Stewart, R. W. Copyright 2019 by Elsevier Health Sciences. Reprinted by permission of Elsevier Health Sciences via the Copyright Clearance Center.


Ball, J. W., Dains, J. E., Flynn, J. A., & Solomon, B. S., & Stewart, R. W. (2019). Head and neck: Key points. In Seidel's guide to physical examination: An interprofessional approach (9th ed.). St. Louis, MO: Elsevier Mosby.


Credit Line: Seidel's Guide to Physical Examination, 9th Edition by Ball, J. W., Dains, J. E., Flynn, J. A., Solomon, B. S., & Stewart, R. W. Copyright 2019 by Elsevier Health Sciences. Reprinted by permission of Elsevier Health Sciences via the Copyright Clearance Center.


Ball, J. W., Dains, J. E., Flynn, J. A., Solomon, B. S., & Stewart, R. W. (2019). Eyes: Student checklist. In Seidel's guide to physical examination: An interprofessional approach (9th ed.). St. Louis, MO: Elsevier Mosby.


Credit Line: Seidel's Guide to Physical Examination, 9th Edition by Ball, J. W., Dains, J. E., Flynn, J. A., Solomon, B. S., & Stewart, R. W. Copyright 2019 by Elsevier Health Sciences. Reprinted by permission of Elsevier Health Sciences via the Copyright Clearance Center.


Ball, J. W., Dains, J. E., Flynn, J. A., Solomon, B. S., & Stewart, R. W. (2019). Eyes: Key points. In Seidel's guide to physical examination: An interprofessional approach (9th ed.). St. Louis, MO: Elsevier Mosby.


Credit Line: Seidel's Guide to Physical Examination, 9th Edition by Ball, J. W., Dains, J. E., Flynn, J. A., Solomon, B. S., & Stewart, R. W. Copyright 2019 by Elsevier Health Sciences. Reprinted by permission of Elsevier Health Sciences via the Copyright Clearance Center.


Ball, J. W., Dains, J. E., Flynn, J. A., Solomon, B. S., & Stewart, R. W. (2019). Ears, nose, and throat: Student checklist. In Seidel's guide to physical examination: An interprofessional approach (9th ed.). St. Louis, MO: Elsevier Mosby.


Credit Line: Seidel's Guide to Physical Examination, 9th Edition by Ball, J. W., Dains, J. E., Flynn, J. A., Solomon, B. S., & Stewart, R. W. Copyright 2019 by Elsevier Health Sciences. Reprinted by permission of Elsevier Health Sciences via the Copyright Clearance Center.


Ball, J. W., Dains, J. E., Flynn, J. A., Solomon, B. S., & Stewart, R. W. (2019). Ears, nose, and throat: Key points. In Seidel's guide to physical examination: An interprofessional approach (9th ed.). St. Louis, MO: Elsevier Mosby.


Credit Line: Seidel's Guide to Physical Examination, 9th Edition by Ball, J. W., Dains, J. E., Flynn, J. A., Solomon, B. S., & Stewart, R. W. Copyright 2019 by Elsevier Health Sciences. Reprinted by permission of Elsevier Health Sciences via the Copyright Clearance Center.


Colyar, M. R. (2015). Advanced practice nursing procedures. Philadelphia, PA: F. A. Davis.


Credit Line: Advanced practice nursing procedures, 1st Edition by Colyar, M. R. Copyright 2015 by F. A. Davis Company. Reprinted by permission of F. A. Davis Company via the Copyright Clearance Center.


Chapter 71, “Visual Function Evaluation: Snellen, Illiterate E, Pictorial



     This section explains the procedural knowledge needed to perform eyes, ears, nose, and mouth procedures.

Sullivan, D. D. (2019). Guide to clinical documentation (3rd ed.). Philadelphia, PA: F. A. Davis.


Chapter 2, "The Comprehensive History and Physical Exam" (Previously read in Weeks 1, 3, 4, and 5)

Bedell, H. E., & Stevenson, S. B. (2013). Eye movement testing in clinical examination. Vision Research 90, 32–37. doi:10.1016/j.visres.2013.02.001. Retrieved from https://www.sciencedirect.com/science/article/pii/S0042698913000217


Rubin, G. S. (2013). Measuring reading performance. Vision Research, 90, 43–51. doi:10.1016/j.visres.2013.02.015. Retrieved from http://www.sciencedirect.com/science/article/pii/S0042698913000436


Harmes, K. M., Blackwood, R. A., Burrows, H. L., Cooke, J. M., Harrison, R. V., & Passamani, P. P. (2013). Otitis media: Diagnosis and treatment. American Family Physicians, 88(7), 435–440.


Otolaryngology Houston. (2014). Imaging of maxillary sinusitis (X-ray, CT, and MRI). Retrieved from http://www.ghorayeb.com/ImagingMaxillarySinusitis.html


This website provides medical images of sinusitis, including X-rays, CT scans, and MRIs (magnetic resonance imaging).



Homework is Completed By:

Writer Writer Name Amount Client Comments & Rating
Instant Homework Helper

ONLINE

Instant Homework Helper

$36

She helped me in last minute in a very reasonable price. She is a lifesaver, I got A+ grade in my homework, I will surely hire her again for my next assignments, Thumbs Up!

Order & Get This Solution Within 3 Hours in $25/Page

Custom Original Solution And Get A+ Grades

  • 100% Plagiarism Free
  • Proper APA/MLA/Harvard Referencing
  • Delivery in 3 Hours After Placing Order
  • Free Turnitin Report
  • Unlimited Revisions
  • Privacy Guaranteed

Order & Get This Solution Within 6 Hours in $20/Page

Custom Original Solution And Get A+ Grades

  • 100% Plagiarism Free
  • Proper APA/MLA/Harvard Referencing
  • Delivery in 6 Hours After Placing Order
  • Free Turnitin Report
  • Unlimited Revisions
  • Privacy Guaranteed

Order & Get This Solution Within 12 Hours in $15/Page

Custom Original Solution And Get A+ Grades

  • 100% Plagiarism Free
  • Proper APA/MLA/Harvard Referencing
  • Delivery in 12 Hours After Placing Order
  • Free Turnitin Report
  • Unlimited Revisions
  • Privacy Guaranteed

6 writers have sent their proposals to do this homework:

Smart Accountants
University Coursework Help
Helping Hand
Top Essay Tutor
Writer Writer Name Offer Chat
Smart Accountants

ONLINE

Smart Accountants

I feel, I am the best option for you to fulfill this project with 100% perfection. I am working in this industry since 2014 and I have served more than 1200 clients with a full amount of satisfaction.

$95 Chat With Writer
University Coursework Help

ONLINE

University Coursework Help

Hi dear, I am ready to do your homework in a reasonable price.

$102 Chat With Writer
Helping Hand

ONLINE

Helping Hand

I am an Academic writer with 10 years of experience. As an Academic writer, my aim is to generate unique content without Plagiarism as per the client’s requirements.

$100 Chat With Writer
Top Essay Tutor

ONLINE

Top Essay Tutor

I have more than 12 years of experience in managing online classes, exams, and quizzes on different websites like; Connect, McGraw-Hill, and Blackboard. I always provide a guarantee to my clients for their grades.

$105 Chat With Writer

Let our expert academic writers to help you in achieving a+ grades in your homework, assignment, quiz or exam.

Similar Homework Questions

Someday i died korean book english - My mistress eyes are nothing like the sun analysis - My phoenix edu forward apply - Quantitative and Qualitative Research - Power point - Investment Firm cybercrime risk assesment - GRAVIMETRIC DETERMINATION OF CALCIUM AS CaC2O4·H2O FORMAL LAB REPORT - What is a google subscriber phone number - Maths - Foundation degree in person centred counselling - BCJ 4301 Management and Supervision in Criminal Justice - Assignment 2 analysis on food security - High contact and low contact services ppt - Pumicestone passage marine park - Why was cafod founded - Conveyor belt project management - Louis vuitton in japan case study analysis - Bohr rutherford diagram periodic table - Critical thinking paper apa format - Futility wilfred owen poem analysis - Health care, Policy analysis paper - 9. read 1 corinthians 15:42-57 and list three characteristics of the glorified state. - Alexa fluor 546 phalloidin - How to find tributary area - Whs workplace inspection checklist - How to write a music concert report - Aging Adult Case Study - Guided learning packages week c - Damage for ductile metals abaqus - Nursing. - John hopkins ebp model steps - How many feet of copper wire in a pound - Composite risk management worksheet - 4 stages of prodg - Case analysis - Something i am grateful for - Devry econ 312 week 3 quiz - Depaul university project management - Cengage comprehensive problem 1 - Litterature - Altruism in society campaign and presentation - Cots time and attendance application - ENTR 5155 Resume - Competitive rivalry and competitive dynamics - The herfindahl index for a pure monopolist is - Persuasive speech cell phones while driving - Pcli lasik cost - Melting point determination apparatus - Which one of the following features distinguishes an ordinary annuity from an annuity due? - Miles to km converter - I need this assignment done as followed as in the content APA style no plagisirism please make sure that everything is in details. - Public Administration unit 7 Discussion - Simon st josephs ferntree gully - Associated alterations of tonsillitis - Https www youtube com watch v 4voubvb4ctu - Case study based assignment on supply chain model - The first day by edward p jones answers - Course advice request monash - Tactus technology ppt - Case study.. Prejudice bias reflection paper [ course: Theories of Human Behavour] - IMC Campaign Plan - Discussion - Social science question - Economics paper, need help completing - Systematic collection and analysis of data - Town and country lovers analysis - Prepare Work for Your "Positive Structural Change" Project. - 21 divided by 4 as a fraction - 9780078024795 pdf - Programming with microsoft visual basic answer key - Excel module 4 sam exam - Clownfish and anemone commensalism - The role of risk in change management - Http extensiononline tamu edu certificates audit php - Berber carpet price per square foot installed - Temptrak temperature monitoring system - Practical strategies for technical communication 2013 pdf - Westberg model of the grieving process - The cyclotron mastering physics - Discuss how science plays a crucial role in many courtrooms - Cisco ws g5486 datasheet - Assignment Help - Domain model in ooad tutorialspoint - The beatles ludwig bop bass drum head lamp display - The book thief ppt - Algebra 1 chapter 8 test answers - Did sandra cisneros have formal training and if so where - Mukul - Ecological footprint lab - The looking glass wars sparknotes - University of indiana plagiarism test - Change active to passive voice exercises - Small bowel enterotomy icd 10 - Commutative property addition worksheet - Evidence based practice - Dr ben terkasher reviews - Boy overboard chapter 4 - Colours of uganda flag - How to use keune hair color - Fare basis code decoder