22 Sep Assignment 1: Practicum Experience – Comprehensi
Assignment 1: Practicum Experience – Comprehensive SOAP Note #3 After completing this week’s Practicum Experience, review the Comprehensive SOAP Note Exemplar and Template in this week’s Resources, and reflect on a patient who presented with musculoskeletal disorders or pain. Describe the patient’s personal and medical history, drug therapy and treatments, and follow-up care. All SOAP notes must be signed and each page must be initialed by your preceptor. When you submit your SOAP Notes, you should include the complete SOAP Note as a Word document and pdf/images of each page that is initialed and signed by your preceptor. You must submit your SOAP Notes using SAFE ASSIGN. Please Note: Electronic signatures are not accepted. If both files are not received by the due date, faculty will deduct points per the Walden Late Policies. By Day 7 of Week 8 This Comprehensive SOAP Note #3 is due. You will submit two files for the Week 8 Comprehensive SOAP Note #3, including a Word document and pdf/images of each page that is initialed and signed by your preceptor by Day 7 of Week 6. I Hope I do not overload you with information. The patient is an 60-year-old African American male with Rhematory arthritis that affects his hands, elbows, knees, and ankles. He has Rheumatoid nodules to hands, elbows, knees, and ankles that have causes deformities. The patient presents to the office with bilateral knee pain. The patient is scheduled for total knee revision to the right knee on October 22, 2019. Patient is worse with weight-bearing and movement. The patient has been currently taken off of all RA medications due to they compromise the immune system. The patient had a total knee replacement in the right knee and became infectious. Currently that knee has been removed, the bone scraped, and metal rods are attached to the bone, and the patient is wearing a custom made brace and using a walker until surgery date. Patient is of the Baptist faith Smokes a pack a day Does not drink Does no illegal or street drugs Lives by himself and very independent has adult children that check on him daily Mother and Father are both Deceased. Mother had RA Allergies: Sulfa and Methotrexate Current Medications: Flomax 0.4 MG 1 Cap in the AM Tramadol HCI 50 MG 1 tab Q8hrs PRN pain Flonase 50 MCG/ACT 1 spray each nostril every day Mucinex Extended-Release 12 Hour 600MG 1 tab every 12 hours PRN for 14 days Discontinued Medications Hydroxychloroquine Sulfate 200 MG 1 tab BID with food or milk Plaquenil 200 MG 1 tab BID with food or milk Sulfasalazine 500 MG 2 tabs BID Prednisone 5 MG 1 tab in the AM Past Medical History RA HSV BPH Sinusitis Surgical History Total right knee replacement 2019 Left Hip replacement Vital Signs: Temp 97.4, HR 92, RR 18, BP 128/84 mmHg, O2 98% RA, WT 141.2 lbs., BMI 18.13 General: In no acute distress, Well developed, Well-nourished Head: Normocephalic Eyes: pupils equal, round, reactive to light and accommodation Ears: WNL Throat: is Clear Neck/Thyroid: neck is supple, full range of motion, no cervical lymphadenopathy Lymph nodes: no palpable adenopathy Skin: no suspicious lesions, warm and dry Heart: Regular rate and rhythm of 92 BPM, S1, S2 normal Lungs: Clear A/P bilaterally, denies any cough or SOB Abdomen: flat, normal bowel sounds, soft and non-tender Back: WNL Musculoskeletal: RA nodules and deformities to elbows, knees, and ankles, Right leg in custom soft straight cast Extremities: 1+ ankles bilaterally Neurological: Nonfocal PSYCH: alert, oriented, cooperative with exam Patient had labs of CBC. CMP, UA, LIPIDS, SED RATE. SED RATE is 62, all other labs are WNL Subjective(25points) ● CC 1 ● Pertinent positives LOCATES 10 ● Pertinent negatives (fromROS) 10 ● Pertinent PMH,SH,andFH 3 ● Medications and drug/food allergies are not included 1 Objective(20points) ● VS including BMI 2 ● Heart and lungs 1 ● Systems or specialty exam techniques that are not necessary to arrive at a diagnosis are included. 5 ● Systems or specialty exam techniques that are necessary to arrive at your diagnosis are omitted. 10 ● Diagnostic tes tresults 2 Assessment–10 pointsfor eachpriority diagnosis(total30points) 30 Plan(15points) ● Medications discontinued(“d/clisinopril10mgdaily”) 1 ● Medications started(“startAvapro 150mgdaily”) 2 ● Alternative therapies if appropriate(1point) 1 ● Health Promotion strategies–patient/family education 3 ● Disease Prevention strategies with time frame if appropriate 3 ● Diagnostic tests ordered with time frame(now,in 2weeks, prior tof/uvisitin3months) 3 ● Referrals or consultations if appropriate 1 ● Follow-up interval 1 Reflection notes(10points) ● What did you learn from this experience?Any ah-ha’s? 10 Total points 100/100 • Preceptor must sign all SOAP notes before submission. Any SOAP note not including the preceptor signature will not be graded, or will be graded as a late submission if necessary.
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