For this assignment, you are to complete a clinical case – narrated PowerPoint report that will follow the SOAP note example provided below. The case report will be based on the clinical case scenario list below.
Step 1 – Read the assigned clinical scenario and using your clinical reasoning skills, decide on the diagnoses. This step informs your next steps.
Step 2 – Document the given information in the case scenario under the appropriate sections, headings, and subheadings of the SOAP note.
Step 3 – Document all the classic symptoms typically associated with the diagnoses in Step 1. This information may NOT be given in the scenario; you are to obtain this information from your textbooks. Include APA citations.
Example of Steps 1 – 3: You decided on Angina after reading the clinical case scenario (Step 1) Review of Symptoms (list of classic symptoms): CV: sweating, squeezing, pressure, heaviness, tightening, burning across the chest starting behind the breastbone GI: indigestion, heartburn, nausea, cramping Pain: pain to the neck, jaw, arms, shoulders, throat, back, and teeth Resp: shortness of breath Musculo: weakness
Step 4 – Document the abnormal physical exam findings typically associated with the acute and chronic diagnoses decided on in Step 1. Again, this information may NOT be given. Cull this information from the textbooks. Include APA citations.
Example of Step 4: You determined the patient has Angina in Step 1 Physical Examination (list of classic exam findings): CV: RRR, murmur grade 1/4 Resp: diminished breath sounds left lower lobe
Step 5 – Document the diagnoses in the appropriate sections, including the ICD-10 codes, from Step 1. Include three differential diagnoses. Define each diagnosis and support each differential diagnosis with pertinent positives and negatives and what makes these choices plausible. This information may come from your textbooks. Remember to cite using APA.
Step 6 – Develop a treatment plan for the diagnoses. Only use National Clinical Guidelines to develop your treatment plans. This information will not come from your textbooks. Use your research skills to locate appropriate guidelines. The treatment plan must address the following: a) Medications (include the dosage in mg/kg, frequency, route, and the number of days) b) Laboratory tests ordered (include why ordered and what the results of the test may indicate) c) Diagnostic tests ordered (include why ordered and what the results of the test may indicate) d) Vaccines administered this visit & vaccine administration forms given, e) Non-pharmacological treatments f) Patient/Family education including preventive care g) Anticipatory guidance for the visit (be sure to include exactly what you discussed during the visit; review Bright Futures website for this section) h) Follow-up appointment with a detailed plan of f/u