APA format Please follow directions below need to have done by 10/10/18 at 9 pm. 3 peer review references. Today 10/10/18 is the third day This week we have lots to do. First off you have a discussion. This should be a SOAP note posted based on the case of your choice. Please pick the one that you feel you will learn the most from here is the SOAP note template his template is for a full history and physical. For this course include only areas that are related to the case. Patient Initials: _______ Age: _______ Gender: _______ Note: The mnemonic below is included for your reference and should be removed before the submission of your final note. L =location O= onset C= character A= associated signs and symptoms T= timing E= exacerbating/relieving factors S= severity Include what the patient tells you, but organize the information. In just a few words, explain why the patient came to the clinic. This is the symptom analysis section of your note. Thorough documentation in this section is essential for patient care, coding, and billing analysis. Paint a picture of what is wrong with the patient. You need to start EVERY HPI with age, race, and gender (e.g., 34-year-old AA male). You must include the . If the CC was “headache”, the LOCATES for the HPI might look like the following example: Location: head Onset: 3 days ago Character: pounding, pressure around the eyes and temples Associated signs and symptoms: nausea, vomiting, photophobia, phonophobia Timing: after being on the computer all day at work Exacerbating/ relieving factors: light bothers eyes, Aleve makes it tolerable but not completely better Severity: 7/10 pain scale Include over-the-counter, vitamin, and herbal supplements. List each one by name with dosage and frequency. Include specific reactions to medications, foods, insects, and environmental factors. Identify if it is an allergy or intolerance. Include illnesses (also childhood illnesses), hospitalizations. Include dates, indications, and types of operations. include obstetric history, menstrual history, methods of contraception, sexual function, and risky sexual behaviors. Include tobacco use, alcohol use, drug use, patient’s interests, ADL’s and IADL’s if applicable, and exercise and eating habits. Include last Tdap, Flu, pneumonia, etc. Include history of parents, grandparents, siblings, and children. Include cultural factors, economic factors, safety, and suppo
rt systems and sexual preference. From head-to-toe, include each system that covers the Chief Complaint, story of Present Illness, and story (this includes the systems that address any previous diagnoses). Remember that the information you include in this section is based on what the patient tells you so ensure that you include all essentials in your case (refer to Chapter 2 of the Sullivan text). Include any recent weight changes, weakness, fatigue, or fever, but . From head-to-toe, include what you see, hear, and feel when doing your physical exam. You only need to examine the systems that are pertinent to the CC, HPI, and story unless you are doing a total H&P- only in this course. Include vital signs, ht, wt, and BMI. Include general state of health, posture, motor activity, and gait. This may also include dress, grooming, hygiene, odors of body or breath, facial expression, manner, level of consciousness, and affect and reactions to people and things. Include any labs, x-rays, or other diagnostics that are needed to develop the differential diagnoses. List your priority diagnosis (es). For each priority diagnosis, list at least three differential diagnoses, each of which must be supported with evidence and guidelines. For holistic care, you need to include previous diagnoses and indicate whether these are controlled or not controlled. These should also be included in your treatment plan. Reflect on your clinical experience, and consider the following questions: What did you learn from this experience? What would you do differently? Do you agree with your preceptor based on the evidence? In order to adequately assess the chest region of a patient, nurses need to be aware of a patient’s history, potential abnormal findings, and what physical exams and diagnostic tests should be conducted to determine the causes and severity of abnormalities. In this Discussion, you will consider how a patient’s initial symptoms can result in very different diagnoses when further assessment is conducted. With regard to the case study you were assigned: an episodic/focused note about the patient in the case study to which you were assigned using the episodic/focused note template provided in week 5 resources. Provide evidence from the literature to support diagnostic tests that would be appropriate for each case. List five different possible conditions for the patient’s differential diagnosis and justify why you selected each. a selection of your colleagues’ responses. Purchase the answer to view it