solved

Question
Answered step-by-step
Asked by PresidentJackal1616

Susan is a 30-year-old registered nurse who works in transitional care. She presents to employee health stating, “My back is killing me. I was helping to transfer a patient and he moved. I thought he was going to fall, so I twisted around to grab onto him and wrenched my back. The pain is terrible, and I can barely walk.” Susan is a healthy young adult, married with a 5-year old. daughter. She has no significant family history. Susan has a past medical history of fractured coccyx as a teenager when she fell during cheerleading practice; no sequelae. She has smoked one-half pack of cigarettes a day since age 15 but is trying to quit. Current medicines include medroxyprogesterone acetate (Depo Provera) injection for birth control every 13 weeks. She is supposed to take calcium, but states that she “always forgets, and it constipates me anyway.” Susan denies any change in bowel/bladder habits.

 

Answered in SOAP format

 

SOAP FORMAT

 

SUBJECTIVE:

Questions you will ask

HPI

PMHx

FHx

SHx

Medications

ROS

 

OBJECTIVE:

Vitals with BMI

Constitutional

HEENT

Cardiac

Pulmo

GI

Musculoskeletal

Skin

GU – if relevant

Always provide a very detailed physical exam, or description of what you want to elicit on your physical exam on the organ system involved in your chief complaint

 

ASSESSMENT:

Working Diagnosis

– provide ICD 10 codes

– provide rationales or pertinent positives and negatives that made you consider the diagnosis

Differential # 1

– diagnosis you cannot miss.

– rationale why it can’t be missed

– provide ICD 10 code

Differential # 2

– what else could it be?

– rationale why you ruled it out

-provide ICD 10 Code

PLAN

Diagnostics
Pharmacological Plan – indicate dosage and regimen, if not indicated state accordingly
Health Education Plan
Referral Plan – if not indicated, state accordingly
Follow-up plan – indicate when patient needs to follow-up and what symptoms to watch out for
Health promotion plan – age-specific health promotion recommendations not related to the case per USPTF
National Standards of Care/ Short Narrative for working diagnosis
SCIENCE
HEALTH SCIENCE
NURSING
NURS 676A

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