What observations did make during the physical assessment?

What observations did make during the physical assessment?

Question Description
I don’t know how to handle this Health & Medical question and need guidance.

Create 45 Soap notes addressing different disorders for the body. The soap notes must address the adult population only. Please address the ROS(review of systems) and PE(physical examination).In your soap template include medications, ICD 10 diagnosis codes ,CPT billing codes and referrals if needed. Attached you will have sample of the templates used. No need to have in text citations or references. Please follow format.

•Subjective: What details did the patient provide regarding his or her personal and medical history?

•Objective: What observations did 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?

Subjective Data

Chief Complain (CC):

History of Present Illness (HPI):

Last Menstrual Period (LMP- if applicable)

Allergies:

Past Medical History:

Family History:

Surgery History:

Social History (alcohol, drug, or tobacco use):

Current medications:

Review of Systems
(Remember to inquire about body systems relevant to the chief complaint and HPI)

Objective Data

Please remember to include an assessment of all relevant systems based on the CC and HPI. The following systems are required in all SOAP notes. You will proceed to assess pertinent systems.

Vital Signs/ Height/Weight:

General Appearance:

HEART:

RESP:

Assessment

A: Differential Diagnosis
Please rule out all differential diagnosis with subjective and objective data and/or lab-work.

1.

2.

3.

B: Medical Diagnosis
Rule in diagnosis with subjective and objective data and lab-work. They need to let us know how they arrived at the diagnosis.

1.

PLAN

A: Orders

Prescriptions with dosage, route, duration, amount prescribed, and if refills are provided
Diagnostic testing
Problem oriented education
Health Promotion/Maintenance Needs
Referrals
Cultural Diversity: What cultural considerations would you suggest for this patient?

Patient/Family Education: If patient is currently on any medications, please address if you want them to discontinue or continue. You always want this to be clear at the end of the visit.

B: Follow-Up Plans (When will you schedule a follow-up appointment and what will you address in the subsequent visit —F/U in 2 weeks; Plan to check annual labs on RTC (return to clinic)

soapassignment.docx
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Assignment: Disorders in Adult population.

Assignment: Disorders in Adult population.

You must proofread your paper. But do not strictly rely on your computer’s spell-checker and grammar-checker; failure to do so indicates a lack of effort on your part and you can expect your grade to suffer accordingly. Papers with numerous misspelled words and grammatical mistakes will be penalized. Read over your paper – in silence and then aloud – before handing it in and make corrections as necessary. Often it is advantageous to have a friend proofread your paper for obvious errors. Handwritten corrections are preferable to uncorrected mistakes.

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The paper must be neatly formatted, double-spaced with a one-inch margin on the top, bottom, and sides of each page. When submitting hard copy, be sure to use white paper and print out using dark ink. If it is hard to read your essay, it will also be hard to follow your argument.


 

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