Description
Please fallow instruction. I need you to make up a soap note using the template for a 17 years male patient diagnose with peptic Ulcer Disease. APA style.
Please and fill out the template completely using your own words for the assessment finding.Fallow the format of the Soap Note, which I sent to you as an attachment. I included the empty soap note template you must plug the information in it. I need you to provide the following: APA format with at least with 5 references no older than 5 years old.
Chief patient compliant
The Diagnosis Constipation: Peptic Ulcer Disease ICD 10 code
Present Medical Assessment (PMH)
Pass Medical Assessment (PSH)
Family History (FH)
Social History (SH)
Review Of System (ROS) completed. Provide complete and concise summary of pertinent information.
3 differential diagnoses with ICD 10 code describe and discuss why choosing them
3 Complete vital sign, BMI
Subjective Information
Complete Objective Information
Lab Tests
Allergies
Complete physical exam with critical elements related to subjective data.
Perform Assessment
Minimum of 3 differentials supported by S + O data. Final diagnosis noted and optimal and thorough subjective and objective assessment is presented for final diagnosis.
Create a Plan
Self-Assessment & Clinical Guidelines
Analyze quality and relevance of S + O data and the evidence for diagnosis. Use of clinical evidence based reasoning and literature in designing plan of care, compare to plan of care.
B) Discuss Peptic Ulcer Disease
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Explanation & Answer
Attached.
Pediatric SOAP Note
Name: Martin Brown
Date:
Sex: male
Age/DOB/Place of Birth: 17 years
SUBJECTIVE
Historian:
Present Concerns/CC
Martin is a 17 year old male experiencing, frequent heart burns, bloating, stomach pains and reduced
appetite Occasionally.
The patient also reported that he frequently felt nauseous which led to vomiting
Child Profile:
Martin is a 17year old male diagnosed with peptic ulcer disease.
HPI:
Martin showed no symptoms of a similar disease in the past history.
He had no allergies to any food substance.
Medications
He is currently taking multi vitamins to boost his deteriorating appetite.
PMH:
Allergies, None
Medication Intolerances: Patients responded well to all medication.
Chronic Illnesses/Major traumas: The patient hard no chronic illness
Hospitalizations/Surgeries: No records of any surgery
thoracotomy Immunizations: None
Family History:
Martin’s father has chronic ulcers and has suffered from the disease for the past 4 years. He has been
admitted to the hospital once as a result of t...