SOAP Note for Ectopic Pregnancy

Anonymous
timer Asked: Feb 4th, 2019
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Question Description

Assignment 2: Practicum – SOAP Note and Time Log

Select a patient that you examined during the last four weeks. With this patient in mind, address the following in a SOAP Note:

  • Subjective: What details did the patient provide regarding 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? Include pharmacologic and nonpharmacologic treatments, alternative therapies, and follow-up parameters, as well as a rationale for this treatment and management plan.
  • Reflection notes: What would you do differently in a similar patient evaluation?

Tutor Answer

Professor_Rey
School: UT Austin

Attached.

Surname | 1
[Your Name]
[Instructor Name]
[Course Number]
[Date]
SOAP Note for Ectopic Pregnancy
Subjective Data
The patient presented was 26 years old female.
The chief complaint presented included nausea and painful vomiting in the morning
for the past 2 weeks. The patient also complained of light vaginal bleeding, abdominal
cramps, pain on the left side of the lower abdomen, dizziness and weakness leading to
occasional fainting, and pain in the shoulder and neck.
The patient stated that it was her first time to experience such and that this was her
first pregnancy. There was no past surgical activity.
Objective Data
The observable signs in the patients were general weakness and the patient could even
vomit. Further physical examination also indicated that there was light vaginal bleeding. The
patient also looked depressed by her con...

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Anonymous
Excellent job

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