For each case study, write a focused SOAP note addressing the patient’s concerns
Case study For each case study, write a focused SOAP note addressing the patient’s concerns. The history must be consistent with the exam, assessment, and plan. You will need to invent findings consistent with your exam and diagnosis, but do not include any additional positive findings. Following the history, create a chart that associates your working hypotheses with the list of rejected hypotheses you choose to include in the history. This is to help you fine-tune what you include from the review of systems. Refer to the Case Study Assignment Instructions for more information. In your paper, explain certain aspects of the plan, including the medications that were started or stopped, diagnostic tests ordered, and strategies recommended for health promotion and disease prevention. Do not include education given to the patient, although this should be included in the plan. Include evidence from the readings. Identify the differences in practice that should be addressed while making the decisions needed to treat this individual. Tim West, a 72-year-old male comes in for a high blood pressure follow-up. The patient has been treated by another provider who no longer works at the practice. Looking through his chart prior to entering the exam room, you learn the following: • Hypertension diagnosed 20 years ago • MI 2 years ago • Medication is HCTZ 25 mg qd and metoprolol 50 mg qd • Allergies – NKA • He smoked 1 ppd x 35 year and quit when he had his MI • His alcohol consumption is 9 oz of wine per day • He is a retired postal worker who is married with two adult children and grandchildren • He had his last tetanus shot 15 years ago • He weighs 200 lbs and is 6′ • His BP is 176/92; P is 48 and regular • Fasting lab results completed 1 month ago • CMP is normal with the exception of K+ – 3.2 (3.5–5.2 mEq/L) • CBC, T4 TSH, Urinalysis all WNL • Total Chol – 230 • HDL – 35 • LDL – 170 • Triglycerides – 200 Previous labs were done 15 months prior and all were normal
The post For each case study, write a focused SOAP note addressing the patient’s concerns appeared first on nursing assignment tutor.
0 comments