Assignment 1: Practicum Experience – Episodic SOAP Note #1

Assignment 1: Practicum Experience – Episodic SOAP Note #1

Assignment 1: Practicum Experience – Episodic SOAP Note #1

In addition to Journal Entries, SOAP Note submissions are a way to reflect on your Practicum Experiences and connect these experiences to your classroom experience. SOAP Notes, such as the ones required in this course, are often used in clinical settings to document patient care. Please refer to the Seidel, et. al. book excerpt and the Gagan article located in this week’s Learning Resources for guidance on writing SOAP Notes.

You must submit your SOAP Notes using SAFE ASSIGN.

To Prepare:

Review the Episodic SOAP Note Exemplar provided in this week’s Resources in preparation for this Assignment.

Use the Episodic SOAP Note Template to complete this Assignment.

After completing this week’s Practicum Experience, select a patient that you examined during the last 3 weeks. With this patient in mind, address the following in a SOAP Note:

Subjective: What details did the patient provide regarding his or her personal and medical history?

Objective: What observations did you make during the physical assessment?

Assessment: What were your differential diagnoses? Provide a minimum of three possible diagnoses. List them from highest priority to lowest priority. What was your primary diagnosis and why?

Plan: What was your plan for diagnostics and primary diagnosis? What was your plan for treatment and management including alternative therapies?

Reflection notes: What would you do differently in a similar patient evaluation?
Please Note: Your Episodic SOAP Note Assignment .

To Prepare:

Review the Episodic SOAP Note Exemplar provided in this week’s Resources in preparation for this Assignment.

Use the Episodic SOAP Note Template to complete this Assignment.

After completing this week’s Practicum Experience, select a patient that you examined during the last 3 weeks. With this patient in mind, address the following in a SOAP Note:

Subjective: What details did the patient provide regarding his or her personal and medical history?

Objective: What observations did you make during the physical assessment?

Assessment: What were your differential diagnoses? Provide a minimum of three possible diagnoses. List them from highest priority to lowest priority. What was your primary diagnosis and why?

Plan: What was your plan for diagnostics and primary diagnosis? What was your plan for treatment and management including alternative therapies?

Reflection notes: What would you do differently in a similar patient evaluation?

NEW PATIENT SOAP NOTE

NEW PATIENT ALLERGIES: Penicillin, Seasonal allergies CURRENT MEDS: HISTORY OF PRESENT ILLNESS: Patient is 28 year old male who presents to the clinic with complaints of persistent cough x 1 week, patient states the cough worsens his asthma symptoms. Patient reports waking up with shortness of breath and needing breathing treatment in the middle of the night for past few days. Patient states he is taking his inhalers almost around the clock now. Patient reports sneezing and runny nose.

Patient reports taking 1 hour nebulizer treatment last night. Pt reports feeling depressed. Pt reports he experienced loss of 3 friends to gun violence in the past. SOCIAL HABITS: smoker daily Marijuana smoker.   Alcohol: none PAST HISTORY: Asthma. PTSD FAMILYHISTORY: Father: CVA Mother: Breast Cancer, Hyperthyroidism Spouse: None Brothers: Lt eye Blindness Sisters: None Children: None SYSTEM REVIEW GENERAL: No weight change, generally healthy, no change in strength or exercise tolerance.

HEAD:   Headaches during coughing spells, no vertigo, no injury. EYES: Normal vision, EARS: No change in hearing, no tinnitus, no vertigo.

NOSE: No epistaxis, no discharge. MOUTH: No dental difficulties, no gingival bleeding, no use of dentures.

NECK: No stiffness, no pain, no tenderness, no noted masses.

BREAST: No noted lumps, no tenderness, no swelling, no nipple discharge.

CHEST: Shortness of breath, productive cough, reports no wheezing. Taking more rescue inhalers more than usual. Patient states he his inhalers about every 2 hours while awake. States he is awaken from his sleep unable to breath and needing nebulizer treatment.

HEART: No chest pains, no palpitations, no syncope, no orthopnea.

ABDOMEN: No change in appetite, no abdominal pains, no bowel habit changes, GU: No urinary urgency, no dysuria, no change in nature of urine.

MUSCULOSKELETAL: No pain in muscles or joints, no limitation of range of motion, no paresthesias or numbness.

NEUROLOGIC: No weakness, no tremor, no seizures, no changes in mentation, no ataxia.

PSYCHATRIC: Patient states he was diagnosed with PTSD in August 2018. Pt states he has seen 3 friends die in his presence. Pt reports not following up after the diagnosis. He has been self-medicating with marijuana. Denies suicidal thoughts.

Objective

GENERAL: Repeat 128/86. in no acute distress. HEAD: Rashes noted in posterior left side.  Normocephalic,

EYES: PERRLA, EOM’s full, conjunctivae clear. EARS: EAC’s clear, TM’s normal. NOSE: Swollen, boggy mucosa, reddened left nostril.

THROAT: Reddened mucosa.  NECK: Supple, no masses, no thyromegaly, no bruits. CHEST: Inspiratory wheezing. HEART: RR, no murmurs, no rubs, no gallops. ABDOMEN: Soft, no tenderness, no masses, BS normal. GU: Deferred.

RECTAL: Deferred BACK: Normal curvature, no tenderness.

EXTREMITIES: no deformities, no edema, no erythema.

NEURO: Physiological, no localizing findings. SKIN: Normal, no rashes, no lesions noted. PROSTATE: Deferred EXTREMITIES: Warm, well perfused, no edema. LAB ORDERED TODAY: X-RAY: EGK:.

 

Assessment

No assessment recorded.

Diagnoses attached to this encounter:

• (J45.909) Unspecified asthma, uncomplicated
• (R05) Cough

Acute

• (J30.9) Allergic rhinitis, unspecified

Plan

 

-Acute asthma exacerbation

Flonase

Breo

Singulair 10 mg Oral Daily

Claritin 10mg Oral daily

Bromfed

Albuterol

Psychology referral given

 

increase fruits and veg. avoid second hand smoke. Avoid greasy food and cut down fried foods. Bake or boil. exercise 30min daily or 1 hour 4 days of the week. Walking in safe area is a good exercise, or stationary bike, dancing , walking in one spot at home works well too. Discussed my plate food guideline with pt. RTC 2 weeks.

 

Medications attached to this encounter:

• Albuterol Sulfate (Proventil HFA) 108 (90 Base) MCG/ACT Inhalation Aerosol Solution Sig: 2 puffs inhaled orally every 4 hours as needed
• Fluticasone Furoate-Vilanterol (Breo Ellipta) 100-25 MCG/INH Inhalation Aerosol Powder Breath Activated Sig: 1 puff inhaled orally daily
• Loratadine (Claritin) 10 MG Oral Tablet Sig: Take 1 tablet (10 mg) by mouth daily
• Montelukast Sodium (Singulair) 10 MG Oral Tablet Sig: Take 1 tablet (10 mg) by mouth daily
• Pseudoephed-Bromphen-DM (Bromfed DM) 30-2-10 MG/5ML Oral Syrup Sig: 10 ml orally every 4 hours as needed

Orders

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