Develop a focused SOAP note for the abnormal finding.

Overview

The goal of this assignment is to practice writing a SOAP note for a sick or episodic visit related to the focus system(s) reviewed in this week’s learning materials. Review the SOAP Note Rubric.
Instructions

Choose an abnormal finding related to the content that was covered this week. Examples from this week would include: hair loss, thickening of the nails, rash, skin lesion, fatigue, malaise, etc.(please pick one of these issues).

Develop a focused SOAP note for the abnormal finding. You do not need to find a patient to match this finding. The point is for you to think about what the HPI would be, what the rest of the history may look like, what the objective findings will be, the potential differential diagnoses, and the plan. In other words, you are creating the patient scenario and documenting it in SOAP format. Please be sure to include all relevant information and not just the system the abnormal finding is in.

I am attaching the rubric, please follow it closely as my professor is obsessed with rubrics and takes points off of any part that is missing

Try not to give the patient complex histories, be through but it doesn’t have to be complicated . It’s ok to say they had no previous illnesses, surgeries, hospitalization. No allergies, no surgical history, no medical probs, take no meds, etc. Be sure to include social/sex history – ETOH, drugs, monogamous, STI prevention, no hx of STI testing, etc. Pay attention to age and gender because she will ding on preventive care – pap smears, birth control, prostate exams, mammograms after age 40, colonoscopies age 45, etc. The older the patient the more requirements so consider that.

Use this site for vaccine requirements by age – Adult Immunization Schedule .
Use this for screenings by age but it’s not the most complete (google worked well for me too) – US Preventive Service Task Force

Make sure your differentials are done well and start with the most likely first. It’s ok to work backwards here – pick your dx, find the references, use the presenting symptoms in the references to write your HPI, subjective and objective sections. Pt. X presents with symptoms of Otitis media, other dx could include otitis externa or… Then one paragraph for each dx…Symptoms of otitis media include (what do they have that aligns with dx)… Negative symptoms for otitis media include (what symptoms are missing or what symptoms are present but don’t point to this dx)… repeat for each dx. Use UpToDate and the books as references for best results. Dains has differentials by symptoms and UpToDate will sometimes have differential dx listed.

Also use the objective exam headers from Bates (Ch4?) and delete or limit the ones not needed based on dx. So if your dx is ear infection, don’t document a genital or musculoskeletal exam and keep exam focused on the problem, so don’t do a full eye exam for an ear infection.

Don’t forget diagnostic testing – labs, xray, cultures, etc. Do plenty of teaching, not just on meds and include prevention, follow up plan, what to do if symptoms worsen, referrals if needed, etc.

If you have any questions please message me

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