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

Soap note with differential diagnosis

07/11/2020 Client: arwaabdullah Deadline: 12 Hours

Comprehensive SOAP Template

Patient Initials: _______ Age: _______ Gender: _______

Note: The mnemonic below is included for your reference and should be removed before the submission of your final note.

O = onset of symptom (acute/gradual)

L= location

D= duration (recent/chronic)

C= character

A= associated symptoms/aggravating factors

R= relieving factors

T= treatments previously tried – response? Why discontinued?

S= severity

SUBJECTIVE DATA: Include what the patient tells you, but organize the information.

Chief Complaint (CC): In just a few words, explain why the patient came to the clinic.

History of Present Illness (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. 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:

1. Location

2. Quality

3. Quantity or severity

4. Timing, including onset, duration, and frequency

5. Setting in which it occurs

6. Factors that have aggravated or relieved the symptom

7. Associated manifestations

Medications: Include over-the-counter, vitamin, and herbal supplements. List each one by name with dosage and frequency.

Allergies: Include specific reactions to medications, foods, insects, and environmental factors. Identify if it is an allergy or intolerance.

Past Medical History (PMH): Include illnesses (also childhood illnesses), hospitalizations., and

Past Surgical History (PSH): Include dates, indications, and types of operations.

Sexual/Reproductive History: If applicable, include obstetric history, menstrual history, methods of contraception, sexual function, and. risky sexual behaviors.

Personal/Social History: Include tobacco use, alcohol use, drug use, patient’s interests, ADL’s and IADL’s if applicable, and exercise and eating habits.

Immunization History: Include last Tdap, Flu, pneumonia, etc.

Significant Family History: Include history of parents, grandparents, siblings, and children.

Lifestyle: Include cultural factors, economic factors, safety, and support systems and sexual preference.

Review of Systems: From head-to-toe, include each system that covers the Chief Complaint, History of Present Illness, and History (this includes the systems that address any previous diagnoses). Remember that the information you include in this section is based on what the patient tells you. To ensure that you include all essentials in your case, refer to Chapter 2 of the Sullivan text

General: Include any recent weight changes, weakness, fatigue, or fever, but do not restate HPI data here.

HEENT:

Neck:

Breasts:

Respiratory:

Cardiovascular/Peripheral Vascular:

Gastrointestinal:

Genitourinary:

Musculoskeletal:

Psychiatric:

Neurological:

Skin: Hematologic:

Endocrine:

Allergic/Immunologic:

OBJECTIVE DATA: From head-to-toe, include what you see, hear, and feel when doing your physical exam.. Do not use “WNL” or “normal.” You must describe what you see.

Physical Exam:

Vital signs: Include vital signs, ht, wt, and BMI. Pulse Ox, Pain level.

General: Include general state of health, posture, motor activity, and gait. This may also include dress, grooming, hygiene, odors of body or breath, facial expression, manner, level of consciousness, and affect and reactions to people and things.

HEENT:

Neck:

Chest

Lungs:

Heart

Peripheral Vascular: Abdomen:

Genital/Rectal:

Musculoskeletal:

Neurological:

Skin:

Include any labs, x-rays, or other diagnostics that are needed to develop the differential diagnoses IF YOU ALREADY HAVE RESULTS.

ASSESSMENT: List your priority diagnosis(es). For each priority diagnosis, list at least three differential diagnoses, each of which must be supported with evidence and guidelines. For holistic care, you need to include previous diagnoses and indicate whether these are controlled or not controlled. These should also be included in your treatment plan.

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

Treatment Plan: If applicable, include both pharmacological and non-pharmacological strategies, alternative therapies, follow-up recommendations, referrals, consultations, and any additional labs, x-ray, or other diagnostics. Support the treatment plan with evidence and guidelines.

Health Promotion: Include exercise, diet, and safety recommendations, as well as any other health promotion strategies for the patient/family. Support the health promotion recommendations and strategies with evidence and guidelines.

Disease Prevention: As appropriate for the patient’s age, include disease prevention recommendations and strategies such as fasting lipid profile, mammography, colonoscopy, immunizations, etc. Support the disease prevention recommendations and strategies with evidence and guidelines.

REFLECTION: Reflect on your clinical experience, and consider the following questions: What did you learn from this experience? What would you do differently? Do you agree with your preceptor based on the evidence? This is worth 25 points!

References: Should use two peer-reviewed journal articles or references to support your reflection and differentials as well as any textbooks used.

© 2014 Laureate Education, Inc. Page 3 of 3

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:

Buy Coursework Help
Quality Homework Helper
Essay Writing Help
Top Grade Essay
Peter O.
Writer Writer Name Offer Chat
Buy Coursework Help

ONLINE

Buy Coursework Help

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

$62 Chat With Writer
Quality Homework Helper

ONLINE

Quality Homework Helper

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

$62 Chat With Writer
Essay Writing Help

ONLINE

Essay Writing Help

I am a qualified and experienced Writer, Researcher, Tutor, analyst and Consultant. I hold MBA (Strategic Management) (Finance and Marketing) & CPA.K (Accounting and Finance.)

$62 Chat With Writer
Top Grade Essay

ONLINE

Top Grade Essay

Working on this platform from a couple of time with exposure of dynamic writing skills gathered with years experience on different other websites.

$62 Chat With Writer
Peter O.

ONLINE

Peter O.

Hello, I can assist you in writing attractive and compelling content on ganja and its movement globally. I will provide with valuable, informative content that you will appreciate. The content will surely hit your target audience. I will provide you with the work that will be according to the needs of the targeted audience and Google’s requirement.

$55 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

Top front and side views of 3d objects - Leadership research findings practice and skills 8th edition pdf - Report cover page format - Section 3 case study.... - A workbook for aphasia - Network diagram with ip addresses - Egyptian civiliaztion - University of ottawa political science - The new power program new protocols for maximum strength pdf - On the waterfront quotes - Poem - Assignment - Grade 6 speech examples - Casale v-drive service manual - Driven damped harmonic oscillator - The great wall of china worksheet answers - John curtin prime ministerial library - A fitness appraisal may include - Composite functions word problems with answers - Thomson flight tom 814 - Vce theatre studies monologues 2021 - Mo co 6 pph3 - __________ is a form of artwork arranged from cut out or torn material pasted onto a surface. - Psychology from inquiry to understanding 3rd ed - Connectivity and its discontents by sherry turkle essay - Revalorism - Contemporary issues in accounting subject - OE W 1 D - Discussion - Common holy days in jewish religious traditions worksheet - End of Life - Difference between classical and carnatic music - Short student council speeches - East of eden setting - Conceptual database design definition - Nicholas carr is google making us stupid pdf - Received view vs perceived view in nursing - Bartender print to file - Pls classes wilkes university - NTC/300: Cloud Technologies - Discussion - University of delaware interview - Montante, s. (2004). thinking on paper. literary cavalcade, 57(3), 36-37. - Errors in melting point determination - Weeko 1 res - Personal interest project society and culture - Discussion 1 - Project management simulation scope resources schedule v2 - Non identifying relationship erd - Yash raj films casting director contact - The chair of the operations management department at quality - Reflection Paper - Information visualization and visual data mining - Week 4 Discussion Question - Rayleigh scattering phase function - Ceiling joist span tables mgp10 - Agassi company uses a job order cost system - Job order costing journal entries example - Why are coke and pepsi considered an oligopoly - Wig shop churchill hospital oxford - Kronecker delta index notation - Www math odu edu bogacki lat - Nur601- Module 4 Discussion - Wk8-16 - Salesforce connected customer report 2019 - 2 - Optare solo workshop manual - Uts student centre call - Office 2016 integrated applications project 2 word access excel - Discusison(DF) - Name three specific consequences of the boston busing crisis - Hen rebellion animal farm - Assisting a person with active and passive movement - Sccm remote control viewer - Nz maths learning objects - Vulnerable Populations - Www science teachers com earth htm answers - Selected currently preferred) specialty and second-preferred specialty - Jack sonni leaves dire straits - Murfin's market willard weekly ad - 6es7 138 4fa05 0ab0 hardware update - Client consultation card for spa - Provide a reflection of at least 500 words (or 2 pages double spaced) of how the knowledge, skills, or theories of this course security architecture and design have been applied, or could be applied, in a practical manner to your current work environment. - Mark stauder hackensack meridian health - The islamia university of bahawalpur - Al3+ ion electron configuration - Blue ocean strategy tata nano - Education business plan template - Caseware idea free download - Effective Communication with Diverse Audiences - Nr 511 week 4 midterm - PHOTOGRAPHY AND CINEMA - Michelin fleet solutions case study answers - Merge data files spss - Reply to each post (Must be 175 words long) in your owe words. - Skyjack scissor lift service manual - Key characteristics of history lens - What mechanisms produce high precipitation at temperate latitudes - Brooks australia smoke alarm manual - Transcultural integrative model - Which protozoan group consists solely of parasitic forms