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Asked by aluni001

 

Create a SOAP note, based only on the information you can glean from the history and physical assessment in the video. Given this is a focused assessment and the physical exam is not verbalized by the provider, this is the correct information

T 98.7F, P 100, R 16, BP 118/70

* Lung sound clear in all auscultated quadrants

* Heart sounds, normal S1, S2. Rhythm regular.

* Reflexes +2

* Muscle strength of arms, shoulders and hands +3

 Keep in mind, this is a video of a osteopathic medicine (think DO) student doing the encounter. She does an osteopathic procedure. You can disregard that minute or two of the video. 

SOAP note should include Working diagnosis, differential diagnoses with rationale (with cited sources) for that differential diagnosis, and plan. Keep in mind that this course is focused on History and Physical Assessment. It is imperative that part be thorough and detailed. For the plan, use your text and available “point of care” resources (for example Epocrates). 

5. Follow the grading rubric as you develop the SOAP note.

 

Link to video:

https://www.youtube.com/watch?v=MzoeBJyVlE0 

SCIENCE
HEALTH SCIENCE
NURSING
NGR 6002L

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