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Please review the rubric for the complete instructions for this assignment. 

S – focused history based on the chief complaint and include the 7 characteristics of a symptom, pertinent medical histories, review of systems  (2 points)

O – Document findings of physical examination   (2 points)

A – Give 3 differential diagnoses – three possible diagnoses (with codes) based on history and physical (3 points)

Keep in mind the 3 differential diagnoses should directly be related to the CC and the HPI. The problem list would include the patient’s other co-morbidities.

Give a scholarly defense of the ONE diagnosis that you chose.

P – Plan of care, including both pharmacological and non-pharmacological treatments, any diagnostic tests ordered, health promotion, and problem list. (3 points)

Problem List:

1. diagnosis from this visit

2. any other co-morbidities (from the medical history)

 

Create 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

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

4. You will do a full SOAP note that includes 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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