This assignment comes in 2 parts. Part 1 is a discussion of 300 words and 1 reference and 2 peer responses of 150 words each one and 1 reference. Part 2 is a SOAP note. Please follow the template attached and the instructions in the rubric.
Discussion
Week 1 Discussion
Instructions: Pick one case scenario to discuss in your initial post. For your peer responses, please reply to the case scenario you did not choose for the initial post. You are expected to respond to two different peers.
Case scenario 1: A 55-year-old male patient presented with a chief complaint of headache onset 7 days ago. He described the pain as severe, constant headache associated with a subjective fever of 102F, chills, and body malaise.
Write a brief SOAP note regarding this patient. Make sure to include your answers to these questions in your SOAP-Note.
- Subjective:
- What other relevant questions should you ask regarding HPI?
- What other medical history questions should you ask?
- What other social history should you ask?
- Objective:
- What are the common clinical symptoms that you will assess for this patient?
- What other tests or procedures (Lab or Diagnostic) would you perform or order for this patient?
- Complete the table to help you decide on differentials and final diagnoses.
Compare CSF in Bacterial Versus Viral Meningitis Appearance Bacterial Viral Opening Pressure Cells Total Protein Glucose Culture
- Diagnosis:
- What are the top 3 differential diagnoses you would consider for this patient, and what is your rationale?
- What is the final diagnosis? How did you rule in/out the other diagnosis?
- Plan:
- What is the gold standard treatment for this patient?
Case Scenario 2: A 60-year-old female who was taken to the ED via EMS due to a sudden onset of left-sided body weakness. The last known to be normal was 2 hours ago. The patient has PMH of HTN, HLD, and MI with 2 stents (2019). You are the provider in the ED and are assigned to manage this patient.
Write a brief H&P regarding this patient. Make sure to include your answers to these questions in your H&P.
- Subjective:
- What pertinent questions will you ask the patient and/or the family?
- What are the risk factors of this patient?
- What other questions would you ask to help you differentiate the clinical signs and symptoms that mimic stroke?
- Objective:
- Complete the table below to differentiate the clinical signs and symptoms of stroke depending on the affected area.
Cerebral Vessel Involved Clinical Manifestations Middle cerebral artery (MCA) Anterior cerebral artery (ACA) Posterior cerebral artery (PCA) Vertebral and basilar arteries Cerebral strokes Lacunar strokes - What tests or procedures (Lab or Diagnostic) would you perform or order for this patient?
- What other diagnostic tools would you use to help you diagnose the patient?
- Complete the table below to differentiate the clinical signs and symptoms of stroke depending on the affected area.
- Diagnosis:
- What are the top 3 differential diagnoses you would consider for this patient, and what is your rationale?
- Plan:
- What is the gold standard treatment for this patient?
- What is your disposition? Admit vs. Discharge? Why?
Assignment
Instructions: Submit a problem-focused SOAP note for grading. You must use an actual patient from your clinical practicum who presents with one or more chief complaints.
Use this template Download this templatefor your SOAP note.
Use the current APA format to style your paper and cite your sources. Review the rubric for more information on how your assignment will be graded.
Rubric
Problem-focused SOAP Note Rubric
Criteria | Ratings | Pts | ||||
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This criterion is linked to a Learning OutcomeSubjective |
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15 pts |
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This criterion is linked to a Learning OutcomeObjective |
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15 pts |
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This criterion is linked to a Learning OutcomeAssessment |
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15 pts |
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This criterion is linked to a Learning OutcomePlan |
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15 pts |
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Total Points: 60 |