Soap Note on Peripheral Vascular Disease, health and medicine homework help

User Generated

Fgurcunavr

Health Medical

Description

Please fill out this template paper by make up a SOAP notes for 50 years old male complain of Peripheral Vascular disease symptoms. Example pain in right leg that gets worse when standing and gets better when raising legs

The plan should include: What test and lab work, pharmacological and non-pharmacological treatment you will order and what you will teach the patient,

I sent the rubric for you to fallow also. APA style with references

Please do not use exactly the same words of the assessment findings that are in the template to avoid plagiarism.

SOAP NOTE that are

Name:

Date:

Time:

Age:

Sex:

SUBJECTIVE

CC:

Reason given by the patient for seeking medical care “in quotes”

HPI:

Describe the course of the patient’s illness, including when it began, character of symptoms, location where the symptoms began, aggravating or alleviating factors; pertinent positives and negatives, other related diseases, past illnesses, surgeries or past diagnostic testing related to present illness.

Medications: (list with reason for med )

PMH

Allergies:

Medication Intolerances:

Chronic Illnesses/Major traumas

Hospitalizations/Surgeries

“Have you every been told that you have: Diabetes, HTN, peptic ulcer disease, asthma, lung disease, heart disease, cancer, TB, thyroid problems or kidney disease or psychiatric diagnosis.”

Family History

Does your mother, father or siblings have any medical or psychiatric illnesses? Anyone diagnosed with: lung disease, heart disease, htn, cancer, TB, DM, or kidney disease.

Social History

Education level, occupational history, current living situation/partner/marital status, substance use/abuse, ETOH, tobacco, marijuana. Safety status

ROS

General

Weight change, fatigue, fever, chills, night sweats, energy level

Cardiovascular

Chest pain, palpitations, PND, orthopnea, edema

Skin

Delayed healing, rashes, bruising, bleeding or skin discolorations, any changes in lesions or moles

Respiratory

Cough, wheezing, hemoptysis, dyspnea, pneumonia hx, TB

Eyes

Corrective lenses, blurring, visual changes of any kind

Gastrointestinal

Abdominal pain, N/V/D, constipation, hepatitis, hemorrhoids, eating disorders, ulcers, black tarry stools

Ears

Ear pain, hearing loss, ringing in ears, discharge

Genitourinary/Gynecological

Urgency, frequency burning, change in color of urine.

Contraception, sexual activity, STDS

Fe: last pap, breast, mammo, menstrual complaints, vaginal discharge, pregnancy hx

Male: prostate, PSA, urinary complaints

Nose/Mouth/Throat

Sinus problems, dysphagia, nose bleeds or discharge, dental disease, hoarseness, throat pain

Musculoskeletal

Back pain, joint swelling, stiffness or pain, fracture hx, osteoporosis

Breast

SBE, lumps, bumps or changes

Neurological

Syncope, seizures, transient paralysis, weakness, paresthesias, black out spells

Heme/Lymph/Endo

HIV status, bruising, blood transfusion hx, night sweats, swollen glands, increase thirst, increase hunger, cold or heat intolerance

Psychiatric

Depression, anxiety, sleeping difficulties, suicidal ideation/attempts, previous dx

OBJECTIVE

Weight BMI

Temp

BP

Height

Pulse

Resp

General Appearance

Healthy appearing adult female in no acute distress. Alert and oriented; answers questions appropriately. Slightly somber affect at first, then brighter later.

Skin

Skin is brown, warm, dry, clean and intact. No rashes or lesions noted.

HEENT

Head is normocephalic, atraumatic and without lesions; hair evenly distributed. Eyes: PERRLA. EOMs intact. No conjunctival or scleral injection. Ears: Canals patent. Bilateral TMs pearly grey with positive light reflex; landmarks easily visualized. Nose: Nasal mucosa pink; normal turbinates. No septal deviation. Neck: Supple. Full ROM; no cervical lymphadenopathy; no occipital nodes. No thyromegaly or nodules. Oral mucosa pink and moist. Pharynx is nonerythematous and without exudate. Teeth are in good repair.

Cardiovascular

S1, S2 with regular rate and rhythm. No extra sounds, clicks, rubs or murmurs. Capillary refill 2 seconds. Pulses 3+ throughout. No edema.

Respiratory

Symmetric chest wall. Respirations regular and easy; lungs clear to auscultation bilaterally.

Gastrointestinal

Abdomen obese; BS active in all 4 quadrants. Abdomen soft, non-tender. No hepatosplenomegaly.

Breast

Breast is free from masses or tenderness, no discharge, no dimpling, wrinkling or discoloration of the skin.

Genitourinary

Bladder is non-distended; no CVA tenderness. External genitalia reveals coarse pubic hair in normal distribution; skin color is consistent with general pigmentation. No vulvar lesions noted. Well estrogenized. A small speculum was inserted; vaginal walls are pink and well rugated; no lesions noted. Cervix is pink and nulliparous. Scant clear to cloudy drainage present. On bimanual exam, cervix is firm. No CMT. Uterus is antevert and positioned behind a slightly distended bladder; no fullness, masses, or tenderness. No adnexal masses or tenderness. Ovaries are non-palpable.

(Male: both testes palpable, no masses or lesions, no hernia, no uretheral discharge. )

(Rectal as appropriate: no evidence of hemorrhoids, fissures, bleeding or masses—Males: prostrate is smooth, non-tender and free from nodules, is of normal size, sphincter tone is firm).

Musculoskeletal

Full ROM seen in all 4 extremities as patient moved about the exam room.

Neurological

Speech clear. Good tone. Posture erect. Balance stable; gait normal.

Psychiatric

Alert and oriented. Dressed in clean slacks, shirt and coat. Maintains eye contact. Speech is soft, though clear and of normal rate and cadence; answers questions appropriately.

Lab Tests

Urinalysis – pending

Urine culture – pending

Wet prep - pending

Special Tests

Diagnosis

Differential Diagnoses

  • 1-
  • 2-
  • 3-

Diagnosis

Plan/Therapeutics

  • Plan:
    • Further testing
    • Medication
    • Education
    • Non-medication treatments

Evaluation of patient encounter

Unformatted Attachment Preview

Subjective Information: “CC”, HPI :OPQRST S NEEDS IMPROVEMENT (.5 points) COMPETENT (1.5 points) EXCELLENT (2 points) Score NOT ACCEPTABLE (0 points) Less than 50% of pertinent information is addressed; or is grossly incomplete and/or inaccurate. Poorly organized and/or limited summary of pertinent information (50%-80%); information other than “S” provided. Well organized; partial but accurate summary of pertinent information (>80%). Complete and concise summary of pertinent information. 2 Less than 50% of pertinent information is addressed; or is grossly incomplete and/or inaccurate. Poorly organized and/or limited summary of pertinent information (50%-80%); information other than “O” provided. Partial but accurate summary of pertinent information (>80%). Complete and concise summary of pertinent information. 2 Less than 50% of diagnoses are listed; or main diagnosis missed; or differential diagnosis not prioritized and/or identified nonexistent problems. Some diagnoses are identified (50%-80%); incomplete or inappropriate diagnosis prioritization; includes nonexistent diagnosis or extraneous information included. Most diagnosis are identified and rationally prioritized, including the “main” diagnosis for the case (>80%). Complete differential diagnosis generated and rationally prioritized; no extraneous information or issues listed. 2 IF f/u: health status since last visit, response to therapies. PMH, PSH, FH, ROS complete Objective Information: O Complete physical exam with critical elements related to subjective data Assessment: Minimum of 3 differentials supported by S + O data A Final diagnosis noted and optimal and thorough subjective and objective assessment is presented for final diagnosis. Comments Plan: Diagnostic tests/therapies/followup, Patient education, health promotion. Medications listed with P Self Assessment & Clinical Guidelines dosage/SE/Education/ Analyze quality and relevance of S + O data and the evidence for diagnosis. Use of clinical evidence based reasoning & literature in designing plan of care, compare to plan of care implemented. Less than 50% of diagnosis have an appropriate and complete treatment plan. Partially complete and/or inappropriate for a few identified diagnosis (50%-80%); information other than “P” provided. Less than 50% of diagnosis include appropriate counseling, monitoring, referral and/or followup plan. Patient education points, monitoring parameters, follow-up plan and referral plan (where applicable) for a few identified problems (50%80%). Did not analyze data gathered. Partially complete and/or inappropriate use of data in assessment data. Did not use clinical evidenced based reasoning. Did not identify literature or treatment guidelines to guide plan of care. Partially identified clinical evidenced based reasoning. Partially identified literature or treatment guidelines to guide plan of care. Mostly complete and appropriate for each identified problem (>80%). Patient education points, monitoring parameters, followup plan and referral plan (where applicable) for >80% of identified problems. Mostly complete and appropriate analysis of data in assessment. General use of clinical based reasoning. Identified literature in most part and clinical guidelines in plan of care development identified. Specific, appropriate and justified recommendations (including drug name, strength, route, frequency, and duration of therapy) for each identified problem. Specific patient education points, monitoring parameters, follow-up plan and (where applicable) referral plan for each identified problem. Analyze quality and relevance of S + O data—supported by evidence and clinical guidelines. Identify needed but missing S + O data. Describe what you would do differently and why. 2 Use of clinical evidence based reasoning & literature in designing plan of care, compare to the actual plan of care implemented Sub-Total: Grammar, Format & APA 2 • Utilizes SU SOAP Template • APA citations are utilized as indicated • Format: length does not exceed 1 page (10-point font; 1-inch margins). If directions are not followed, deduct two points from final score. In addition, follow SU deductions for late submissions. 10 Subtract points for grammar, Format, & APA as indicated • Final Total Please fill out this template paper by make up a SOAP notes for 50 years old male complain of Peripheral Vascular disease symptoms. Example pain in right leg that gets worse when standing and gets better when raising legs The plan should include: What test and lab work, pharmacological and non-pharmacological treatment you will order and what you will teach the patient, I sent the rubric for you to fallow also. APA style with references Please do not use exactly the same words of the assessment findings that are in the template to avoid plagiarism. SOAP NOTE that are Name: Date: Age: Time: Sex: SUBJECTIVE CC: Reason given by the patient for seeking medical care “in quotes” HPI: Describe the course of the patient’s illness, including when it began, character of symptoms, location where the symptoms began, aggravating or alleviating factors; pertinent positives and negatives, other related diseases, past illnesses, surgeries or past diagnostic testing related to present illness. Medications: (list with reason for med ) PMH Allergies: Medication Intolerances: Chronic Illnesses/Major traumas Hospitalizations/Surgeries “Have you every been told that you have: Diabetes, HTN, peptic ulcer disease, asthma, lung disease, heart disease, cancer, TB, thyroid problems or kidney disease or psychiatric diagnosis.” Family History Does your mother, father or siblings have any medical or psychiatric illnesses? Anyone diagnosed with: lung disease, heart disease, htn, cancer, TB, DM, or kidney disease. Social History Education level, occupational history, current living situation/partner/marital status, substance use/abuse, ETOH, tobacco, marijuana. Safety status ROS General Cardiovascular Weight change, fatigue, fever, chills, night sweats, energy level Chest pain, palpitations, PND, orthopnea, edema Skin Respiratory Delayed healing, rashes, bruising, bleeding or skin discolorations, any changes in lesions or moles Cough, wheezing, hemoptysis, dyspnea, pneumonia hx, TB Eyes Gastrointestinal Corrective lenses, blurring, visual changes of any kind Abdominal pain, N/V/D, constipation, hepatitis, hemorrhoids, eating disorders, ulcers, black tarry stools Ears Genitourinary/Gynecological Ear pain, hearing loss, ringing in ears, discharge Urgency, frequency burning, change in color of urine. Contraception, sexual activity, STDS Fe: last pap, breast, mammo, menstrual complaints, vaginal discharge, pregnancy hx Male: prostate, PSA, urinary complaints Nose/Mouth/Throat Musculoskeletal Sinus problems, dysphagia, nose bleeds or discharge, dental disease, hoarseness, throat pain Back pain, joint swelling, stiffness or pain, fracture hx, osteoporosis Breast Neurological SBE, lumps, bumps or changes Syncope, seizures, transient paralysis, weakness, paresthesias, black out spells Psychiatric Heme/Lymph/Endo HIV status, bruising, blood transfusion hx, night sweats, swollen glands, increase thirst, increase hunger, cold or heat intolerance OBJECTIVE Weight BMI Temp Height Pulse General Appearance Depression, anxiety, sleeping difficulties, suicidal ideation/attempts, previous dx BP Resp Healthy appearing adult female in no acute distress. Alert and oriented; answers questions appropriately. Slightly somber affect at first, then brighter later. Skin Skin is brown, warm, dry, clean and intact. No rashes or lesions noted. HEENT Head is normocephalic, atraumatic and without lesions; hair evenly distributed. Eyes: PERRLA. EOMs intact. No conjunctival or scleral injection. Ears: Canals patent. Bilateral TMs pearly grey with positive light reflex; landmarks easily visualized. Nose: Nasal mucosa pink; normal turbinates. No septal deviation. Neck: Supple. Full ROM; no cervical lymphadenopathy; no occipital nodes. No thyromegaly or nodules. Oral mucosa pink and moist. Pharynx is nonerythematous and without exudate. Teeth are in good repair. Cardiovascular S1, S2 with regular rate and rhythm. No extra sounds, clicks, rubs or murmurs. Capillary refill 2 seconds. Pulses 3+ throughout. No edema. Respiratory Symmetric chest wall. Respirations regular and easy; lungs clear to auscultation bilaterally. Gastrointestinal Abdomen obese; BS active in all 4 quadrants. Abdomen soft, non-tender. No hepatosplenomegaly. Breast Breast is free from masses or tenderness, no discharge, no dimpling, wrinkling or discoloration of the skin. Genitourinary Bladder is non-distended; no CVA tenderness. External genitalia reveals coarse pubic hair in normal distribution; skin color is consistent with general pigmentation. No vulvar lesions noted. Well estrogenized. A small speculum was inserted; vaginal walls are pink and well rugated; no lesions noted. Cervix is pink and nulliparous. Scant clear to cloudy drainage present. On bimanual exam, cervix is firm. No CMT. Uterus is antevert and positioned behind a slightly distended bladder; no fullness, masses, or tenderness. No adnexal masses or tenderness. Ovaries are non-palpable. (Male: both testes palpable, no masses or lesions, no hernia, no uretheral discharge. ) (Rectal as appropriate: no evidence of hemorrhoids, fissures, bleeding or masses—Males: prostrate is smooth, non-tender and free from nodules, is of normal size, sphincter tone is firm). Musculoskeletal Full ROM seen in all 4 extremities as patient moved about the exam room. Neurological Speech clear. Good tone. Posture erect. Balance stable; gait normal. Psychiatric Alert and oriented. Dressed in clean slacks, shirt and coat. Maintains eye contact. Speech is soft, though clear and of normal rate and cadence; answers questions appropriately. Lab Tests Urinalysis – pending Urine culture – pending Wet prep - pending Special Tests Diagnosis Differential Diagnoses o o o 123- Diagnosis o Plan/Therapeutics o Plan: ▪ ▪ ▪ ▪ Further testing Medication Education Non-medication treatments Evaluation of patient encounter
User generated content is uploaded by users for the purposes of learning and should be used following Studypool's honor code & terms of service.

This question has not been answered.

Create a free account to get help with this and any other question!

Similar Content

Related Tags