25 Sep Assignment: Practicum Experience – Episodic SOAP
Assignment: Practicum Experience – Episodic SOAP Note #2 After completing this week’s Practicum Experience, reflect on a patient who presented with abdominal 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. I have the patient information below. I feel Like I am leaving something out; just not sure what. I work all weekend and will be checking my email a lot in case you need more information. A lot of results on this patient are pending. I feel 100% sure this patient has cancer and it sadness me. I’m hoping we catch it earlier enough for successful treatment and a full recovery. I will upload the SOAP note template again with Preceptor signature line. I have found one example to look at. Your Soap Notes are always excellent. Patient information 46 year-old African American Female present to the clinic with abdominal pain, bloating, distended abdomen, nausea, difficulty swallowing, hoarsens and weight loss , onset 3 months ago. Patient reports stomach is tight a swollen. Also noted 17.2 lbs in weight loss over the past 3 months. Patient has a history of GERD that has been well controlled with Omperazole 20 MG 1 tab in the A.M. and Ranitidine HCL 150 MG BID. Patient denies any diarrhea, vomiting blood or bloody stools. Vital Signs: Temp 98.6, HR 90 BPM, BP 103/67 mm HG, O2 100% RA, Weight 48.63 KG, BMI 18.99 Index Allergies: PCN Medications: Omperazole 20 MG 1 tab in AM Ranitidine 150 MG BID Single mother of 5 children, smokes a pack a day, non-drinker, Baptist faith, Has used Marijuana in the past. No previous Hospitalizations No Surgeries, Children are all of vaginal delivery Patient is Current on all immunizations; however declines influenza vaccine ASSESSMENT General Appearance: Well developed, Pleasant and cooperative Oral: Mucosa is moist, missing several molars (Teeth) NECK/THYROID: neck supple, full range of motion, no cervical Lymphadenopathy SKIN: intact, warm and dry, no sucpsious lesions HEART: regular rate and rhythym at 90 BPM, S1 and S2 normal LUNGS: Clear A/P bilaterally on auscultation ADOMEN: Distended, hyper bowels sounds with a lot of gurgling, non tender on palpation, Unable to palpate liver margin. MUSCULOSKELETAL: Normal EXTREMITIES: No clubbing, cyanosis or edema NEUROLOGIC: Nonfocal PSyCH: Alert, Oriented, cooperative with exam Labs: indicated Neutropenia (WBC 1.2), Moderate Anemia (HGC 7.0 and HCT 32.9) HypoKalemia (3.2) Patient has been scheduled for a EGD and colonoscopy At Helena Regional Medical Center with Dr. Reddy. Will make further appointments after the results of EGD and Colonoscopy. Have consulted hematology and oncology for possible urgent care and treatment on this patient. Patient understands based on labs this that she must follow all schedule appointments. Patient also reports she will seek all treatment and will return to office with worsening condition or to the local emergency department. We will continue to monitor HGC and HCT. Tumor • Cancer • Barrett’s Esophagus. • Hiatal Hernia. • Indigestion.. • Ulcers. Subjective (25points) ● CC 1 ● Pertinent positives LOCATES 10 ● Pertinent negatives (fromROS) 10 ● Pertinent PMH ,SH, and FH 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 test results 2 Assessment–10 points for each priority diagnosis(total30points) 30 Plan(15points) ● Medications discontinued(“d/clisinopril10mgdaily”) 1 ● Medications started(“start Avapro 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,priortof/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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