Assessment: What were your differential diagnoses? Provide a minimum of three possible diagnoses.

Select a patient who you examined during the last 4 weeks. With this patient in mind, address the following in a SOAP Note: – Subjective: What details did the patient or parent provide regarding the personal and medical history? Include any discrepancies between the details provided by the child and details provided by the parent, as well as possible reasons for these discrepancies. – Objective: What observations did you make during the physical assessment? Include pertinent positive and negative physical exam findings. Describe whether the patient presented with any growth and development or psychosocial issues. – 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? Include pharmacologic and non-pharmacologic treatments, alternative therapies, and follow-up parameters, as well as a rationale for this treatment and management plan. – Reflection notes: What was your “aha” moment? What would you do differently in a similar patient evaluation? Below is an example of Soap note: Subjective Data Chief Complain: Difficulty swallowing, throat pain, and fever History of Present Illness: This is an 18 years old African American female who presents to the clinic complaining fever, throat pain, and difficulty swallowing for the past three days. She rated her pain as six on a scale of one to ten. The patient described her pain as aching and has increased with severity especially when she tries to swallow. The chills and fever are intermittent. The child also indicated severe loss of appetite and bad breath. Medication: 1- Tylenol 500mg, two tablets every four hours as needed Allergies: No known drug allergies Past Medical History: pneumonia and skin rash Past surgical history: None Personal/Social History: The patient is currently in high school and plays on the basketball team. She was delivered vaginally at 39 weeks of gestation with no complication. She now lives with her parents and three other siblings. Immunization: Received flu shot in October 2015. Family History: Her father has hypertension, asthma, and diabetes. Her mother has hypertension and diabetes. She has one sister and two brothers, with one of the brothers suffering from asthma. Review of Systems: General: Fever, chills, fatigue, and weakness. Skin: reports no rashes, no itching, nor dryness. Eyes: No vertigo, no eye pain, nor visual changes, Ears: No ear discharge, no tinnitus, nor hearing loss. Nose: There is an absence of running nose and nasal congestion. Mouth/throat: difficulty swallowing, throat pain Respiratory: Patient denies chest tightness, no difficulty breathing, and no wheezing. Cardiovascular: fatigue and weakness. Gastrointestinal: The patient complains of loss of appetite.

Click here to request for this assignment help

Powered by WordPress | Designed by: photography charlottesville va | Thanks to ppc software, penny auction and larry goins