I attached the template and also an example of this assignment from a previous student
Review this and previous weeks’ Learning Resources as needed.
Review the case study provided by your Instructor. Based on the provided patient information, think about the health history you would need to collect from the patient.
Consider what physical exams and diagnostic tests would be appropriate in order to gather more information about the patient’s condition. Reflect on how the results would be used to make a diagnosis.
Identify three to five possible conditions that may be considered in a differential diagnosis for the patient.
Consider each patient’s diagnosis. Think about clinical guidelines that might support this diagnosis.
Develop a treatment plan for the patient that includes health promotion and patient education strategies for patients with their condition(s).
The Assignment:
Use the Focused SOAP Note Template to address the following:
Subjective: What details are provided regarding the patient’s personal and medical history?
Objective: What observations did you make during the physical assessment? Include pertinent positive and negative physical exam findings. Describe whether the patient presented with any morbidities or psychosocial issues.
Assessment: Explain your differential diagnoses, providing a minimum of three. List them from highest priority to lowest priority and include their CPT and ICD-10 codes for the diagnosis. What would your primary diagnosis be and why?
Plan: Explain your plan for diagnostics and primary diagnosis. What would your plan be for treatment and management? Include pharmacologic and non-pharmacologic treatments, alternative therapies, and follow-up parameters as well as a rationale for this treatment and management plan.
Reflection notes: Describe your “aha!” moments from analyzing this case.
For your case study, use the following case to complete a focused SOAP note. Make sure to answer all the questions at the end of your SOAP note and follow the rubric for required elements in this case. Add information as necessary to create a cohesive soap note.
Lastly, check your similarity index prior to submission. Each case is unique and you should not have identical parts of the SOAP note from previous assignments. Need to paraphrase information taken from websites and cite as appropriate. References should be in APA format.
Edwin is a 69 year old male who comes in to the clinic today stating that over the past few days, he has had a fever and chills, cough, and has been quite fatigued. He didn’t take his temperature because he did not have a thermometer but he “felt hot”. He says he is coughing up a little phlegm. He states that it hurts when he takes a deep breath. He also states that his appetite has not been very good. He has been taking Tylenol with minimal relief. He has also been drinking teas to try to break up the phlegm.
Edwin is a nonsmoker and non drinker. He has been very healthy and has no medical problems. He has never had surgery.
On exam, his vital signs are: BP 130/80; P 84; R 14; T 103.2; Pulse ox: 94%.
Exam reveals decreased rales and rhonchi, more pronounced in the left lower lung fields, with increased fremitus and dullness to percussion. Chest x-ray reveals a consolidation in the left lower lobe. This appears to confirm that he has pneumonia?
Which bacteria is the leading cause of pneumonia and the one that he most likely has?
What is unusual about this pts history as compared to most pts that are at risk for s.pneumoniae?
In this type of pneumonia, the sputum analysis indicates gram _________ (negative/positive) diplococci. There are also a large number of _______________.
What other bacteria must be considered?
What is the best way to identify the pathologic agent?
The best sputum sample comes from the saliva in the mouth. TRUE OR FALSE
When is the best time to get a sputum sample? Why is that the best time?
When sending the sputum to the lab, how does the lab determine it is an adequate sample?)
Name four other diagnostics that can be done on this patient to further understand his condition.
If obtaining blood cultures, how many sets are typically obtained?
When choosing an antibiotic to treat this pt, it is important to try to cover for all pathogens, especially gram-negative organisms.
When treating on an outpatient basis, what class of drug should be used for this previously healthy man with no use of antimicrobial therapy within the previous 3 months?
Although there have been cases of resistance against this class, it is still recommended for pts without risk. Please write out the rx directions the way with the med and the sig how you would write it for the pt.
The choice of antibiotic therapy depends on three Important factors. What are they?
In most cases, improvement is seen within __________ to _________ hours of initiation of antibiotics
Should cough medicine be recommended? _______ Why or why not?
Name two teaching points to tell the patient.
