PLEASE ANSWER ALL THE QUESTIONS. ICD 10 CODE AND CPT CODES ARE NEEDED.
RESPIRATORY: Pneumonia, Asthma, Bronchitis
For this activity, we will focus on presenting patients in addition to assessing clinical reasoning. You are to select a patient from your clinical setting that presents with a complaint consistent with Respiratory disorders. Report what was done for patients selected from your clinical setting only.
Presentations need to follow SOAP format with reflections. Address the following:
- Subjective (S) =chief complaint or reason patient presented for treatment with pertinent historical information including PMH, Medication, Allergies, PSH, SH, and ROS.
- Objective (O) =exam findings relevant to the chief complaint or reason for a visit including any diagnostic tests [labs or imaging] done at the point of care.
- Assessment (A) = most probable diagnosis includes at least 2 differential diagnoses for the acute problem [new problem] and status of any chronic conditions listed in order of priority.
- Plan (P) =include all appropriate treatment and management of all diagnoses addressed during the visit including patient education, health promotion and disease prevention [age appropriate].
- Reflections- what did you learn, and would you do anything differently (if any).
- Include one peer-reviewed scholarly reference or clinical practice guideline to support your clinical decision making.
- Use APA format for PPT, which always includes a title slide, a reference slide, and APA requirements. Resources found in APA Documents/Resources.
