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
Case Study Instructions 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 diagnosis on exam, but do not include any additional positive findings. Following the history, create a chart that associates your working hypotheses with the list of denies you choose to include in the history. This is to help you fine-tune what you include from the review of systems. 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. Write a SOAP note that addresses the chief complaint for the visit, chronic health problems from previous visits, and strategies recommended for health promotion and disease prevention. Do not change the history provided; however, you may add to the history if it is compliant with the diagnosis. Include the following in your note: • Chief complaint • Focused history including previous history, onset, location, duration, characteristics, associated symptoms, relieving factors, timing, and severity (POLDCARTS) • Pertinent Review of Systems data based on differential diagnoses and included in the subjective portion of the note • Physical exam including appropriate systems based on differential diagnoses Create the exam so that it is consistent with the working differentials as well as any chronic problems that exist. Although the exam will be fictional, it must be consistent with the history, working differentials, and final diagnosis. Write only the confirmed diagnoses in the assessment section, and include a section for differential diagnoses that are seriously being considered and are supported by the history and exam. • Do not use rule outs. • Do not admit the patient to the hospital and, if referred, assume a 2-month delay—the assignment is to manage this patient as in an outpatient setting. Develop an organized treatment plan that is evidence based and promotes lawful practice based on the federal and state regulations of where you reside or plan to practice. Locate a minimum of 5 peer-reviewed sources using the University Library that address evidence-based approaches that support your decisions in the plan. Sources must not be more than 5 years old. If you’re unable to locate recent evidence-based sources, obtain approval from faculty on the resources selected. Include a list of all items in the plan, much like orders would be written. Include the following: • Medications to be started • Medications to be discontinued • Diagnostic tests • Strategies for health promotion and disease prevention • Patient and family education • Interval for follow-up: When will you re-evaluate the patient? • Any diagnostic testing to be done prior to follow-up • Complete a new prescription for each drug ordered. Include refills if appropriate. Cite and reference using APA guidelines.
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