HYPOTHYROIDISM SOAP NOTE PAPER

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HYPOTHYROIDISM SOAP NOTE PAPER

HYPOTHYROIDISM SOAP NOTE PAPER

Hypothyroidism SOAP NOTE

Patient Initials: Age:  Gender:

SUBJECTIVE DATA:

Chief Complaint (CC): “ ”.

History of Present Illness (HPI):

Medications:

Allergies:

Past Medical History (PMH):

Current medication:

Past Surgical History (PSH):

Family History:

Personal/Social History:

Immunization: up to date.

Lifestyle:

Review of Systems:

General:

HEENT:

Neck:

Breasts:

Respiratory:

Cardiovascular/Peripheral Vascular:

Gastrointestinal:

Genitourinary:

Musculoskeletal:

Psychiatric:

Neurological

Skin:

Hematologic:

Endocrine:

OBJECTIVE DATA:

Physical Exam:

Vital signs: Temperature: ; BP:  mmHg; HR: bpm; RR:  /min; Oxygen Saturation: %; Pain: (0-10 scale), Weight lb; Height; BMI

General:.

HEENT:

Neck:

Chest

Lungs:

Heart:

Peripheral Vascular:

Genital/Rectal:

Musculoskeletal:

Neurological:

Skin:

ASSESSMENT:

Differential Diagnosis

1. Hyperthyroidism.

2.

3.

From both the subjective and objective data, it is clear that the main diagnosis is

PLAN:

Treatment Plan: (please prescription with dose)

Non-pharmacological approaches

For the follow-up, the patient should get back to the hospital after

References: 2 or 3 with APA format

Soap Note 2 Chronic Conditions (15 Points)

Pick any Chronic Disease from Weeks 6-10

Follow the MRU Soap Note Rubric as a guide:

Use APA format and must include minimum of 2 Scholarly Citations.

Soap notes will be uploaded to Moodle and put through TURN-It-In (anti-Plagiarism program)

Turn it in Score must be less than 50% or will not be accepted for credit, must be your own work and in your own words. You can resubmit, Final submission will be accepted if less than 50%. Copy paste from websites or textbooks will not be accepted or tolerated. Please see College Handbook with reference to Academic Misconduct Statement.

Please use the sample templates for you soap note, keep these templates for when you start clinicals.

The use of templates is ok with regards of Turn it in, but the Patient History, CC, HPI, The Assessment and Plan should be of your own work and individualized to your made up patient.

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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.

Use a standard 10 to 12 point (10 to 12 characters per inch) typeface. Smaller or compressed type and papers with small margins or single-spacing are hard to read. It is better to let your essay run over the recommended number of pages than to try to compress it into fewer pages.

Likewise, large type, large margins, large indentations, triple-spacing, increased leading (space between lines), increased kerning (space between letters), and any other such attempts at “padding” to increase the length of a paper are unacceptable, wasteful of trees, and will not fool your professor.

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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