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Select a patient. You may use a peer, friend, or family for this assignment, but they must be 18 or older.
Obtain a complete health history from this “patient”
Have the patient pretend they are visiting you for
a “well exam” or
“annual check up” (as opposed to a problem focus) and use the health history template posted in the course.
DO NOT perform any physical exam. You are only doing the
interview portion of the patient visit for this assignment.
Document your findings as you would for a comprehensive visit, including a risk assessment
(at least 3 health risks for example high cholesterol, high blood pressure, high blood sugar, low vitamin D….. any health risk
with rationale)You can be creative in your assessment.
Submit this partial SOAP note (NO Objective section – NO exam) of the history and risk assessment via the assignment tab.
Expectations
· APA format with intext citations
·
Word count minimum of 500, not including references.
· References: 2 high-level scholarly references within the last 5 years in APA format.
· Plagiarism free.
· Turnitin receipt.
SOAP note template
SOAP
SUBJECTIVE:
ID:
CC: “ “
HISTORY OF PRESENT ILLNESS (HPI):
PAST MEDICAL HISTORY
PAST MEDICAL PROCEDURES
MEDICATIONS
ALLERGIES
LMP (as applies)
FAMILY HISTORY
SOCIAL HISTORY
-SEXUAL/REPRODUCTIVE
-TOBACCO USE/Vaping:
-ALCOHOL USE: social drinker
-DRUG USE:
-MARITAL HISTORY:
-OCCUPATION:
-EXERCISE/DIET:
-SLEEP/STRESS:
IMMUNIZATIONS
SPIRITUAL AFFILIATION
REVIEW OF SYSTEMS:
ONLY DOCUMENT WHAT YOU ASKED ABOUT
DO NOT copy and paste this list or you will have a high “Turn-It-In” score. Students should be able to reword and include only what they asked.
CONSTITUTIONAL: denies fever, chills, and loss of appetite, fatigue, or weight loss
EYES: denies blurred vision, scleral icterus, tunnel vision, discharge, pruritus, edema, and redness (date of last eye exam can go here)
EARS, NOSE, MOUTH/THROAT: denies hearing loss, tinnitus, vertigo, discharge, and earache, denies rhinorrhea, stuffiness, sneezing, and epistaxis, denies allergies, denies pain or difficulty swallowing (date of last dental exam can go here)
CARDIOVASCULAR: denies angina, palpitations, orthopnea, paroxysmal nocturnal dyspnea, edema, or dyspnea.
RESPIRATORY: Denies hemoptysis, wheezing, and shortness of breath, cough, or sputum production.
GASTROINTESTINAL: denies, dysphagia, constipation, abdominal pain, hemorrhoids. Reports rectal bleeding with bright red blood, rectal pain, and reflux and history of rectal cancer.
GENITOURINARY: denies urinary urgency, hesitancy, frequency, polyuria, dysuria, hematuria, incontinence, libido changes, and infection. Women: Denies menstrual changes, vaginal discharge, vaginal dryness or pain, or abnormal bleeding. Men: Denies scrotal pain, penis pain, masses, weak stream or erectile dysfunction
MUSCULOSKELETAL: denies stiffness, joint pain, joint swelling, muscle pain, or decreased ROM.
INTEGUMENTARY/BREAST: Denies pruritus, rashes, stria, lesions, wounds, nodules, tumors, eczema, excessive dryness and/or discoloration. Denies breast pain, soreness, lumps, or discharge.
NEURO: denies seizures, headaches, motor weakness, paresthesias, paralysis, memory loss
PSYCH: denies anxiety, depression, mood changes, body image problems, mania, binges, or suicidal thoughts
ENDOCRINE: Denies heat or cold intolerance, weight changes, polyuria, polydipsia, polyphagia, changes in hair, libido or sexual performance
HEMATOLOGIC/LYMPHATIC: Denies excessive bleeding, easy bruising, petechia. Denies enlarged, swollen, or tender lymph nodes
ALLERGY/IMMUNOLOGY: Denies drug/food/seasonal allergies, denies getting sick more frequently than others, or taking longer to recover
OBJECTIVE:
VITAL SIGNS: P: BP: RR: T: 97.8 SpO2 RA: Pain : /10
Ht : Wt : BMI:
PHYSICAL EXAM:
GENERAL survey:
HEENT:
Head
Eyes
Ears
Nose
Throat
Mouth
·
HEART:
RESPIRATORY:
CHEST/BREASTS:
GI:
GU:
LYMPH:
MUSCULOSKELETAL/EXTREMITIES:
SKIN:
NEUROLOGIC:
PSYCHIATRIC:
ASSESSMENT:
Differential Diagnosis:
1.
One possible dx with rationale on why you ruled out
2.
Another
3.
A third (minimum = three)
4.
A fourth
FINAL DX: The chosen diagnosis from above
PLAN:
-Diagnostic plan (labs/xrays/EKG etc.)
-Treatment/Therapeutic Plan: Meds, treatments, diet/exercise/etc. recommendation
-Referrals
-Education
-F/U plan
Select a patient. You may use a peer, friend, or family for this assignment, but they must be 18 or older.
Obtain a complete health history from this “patient”
Have the patient pretend they are visiting you for
a “well exam” or
“annual check up” (as opposed to a problem focus) and use the health history template posted in the course.
DO NOT perform any physical exam. You are only doing the
interview portion of the patient visit for this assignment.
Document your findings as you would for a comprehensive visit, including a risk assessment
(at least 3 health risks for example high cholesterol, high blood pressure, high blood sugar, low vitamin D….. any health risk
with rationale)You can be creative in your assessment.
Submit this partial SOAP note (NO Objective section – NO exam) of the history and risk assessment via the assignment tab.
Expectations
· APA format with intext citations
·
Word count minimum of 500, not including references.
· References: 2 high-level scholarly references within the last 5 years in APA format.
· Plagiarism free.
· Turnitin receipt.
SOAP note template
SOAP
SUBJECTIVE:
ID:
CC: “ “
HISTORY OF PRESENT ILLNESS (HPI):
PAST MEDICAL HISTORY
PAST MEDICAL PROCEDURES
MEDICATIONS
ALLERGIES
LMP (as applies)
FAMILY HISTORY
SOCIAL HISTORY
-SEXUAL/REPRODUCTIVE
-TOBACCO USE/Vaping:
-ALCOHOL USE: social drinker
-DRUG USE:
-MARITAL HISTORY:
-OCCUPATION:
-EXERCISE/DIET:
-SLEEP/STRESS:
IMMUNIZATIONS
SPIRITUAL AFFILIATION
REVIEW OF SYSTEMS:
ONLY DOCUMENT WHAT YOU ASKED ABOUT
DO NOT copy and paste this list or you will have a high “Turn-It-In” score. Students should be able to reword and include only what they asked.
CONSTITUTIONAL: denies fever, chills, and loss of appetite, fatigue, or weight loss
EYES: denies blurred vision, scleral icterus, tunnel vision, discharge, pruritus, edema, and redness (date of last eye exam can go here)
EARS, NOSE, MOUTH/THROAT: denies hearing loss, tinnitus, vertigo, discharge, and earache, denies rhinorrhea, stuffiness, sneezing, and epistaxis, denies allergies, denies pain or difficulty swallowing (date of last dental exam can go here)
CARDIOVASCULAR: denies angina, palpitations, orthopnea, paroxysmal nocturnal dyspnea, edema, or dyspnea.
RESPIRATORY: Denies hemoptysis, wheezing, and shortness of breath, cough, or sputum production.
GASTROINTESTINAL: denies, dysphagia, constipation, abdominal pain, hemorrhoids. Reports rectal bleeding with bright red blood, rectal pain, and reflux and history of rectal cancer.
GENITOURINARY: denies urinary urgency, hesitancy, frequency, polyuria, dysuria, hematuria, incontinence, libido changes, and infection. Women: Denies menstrual changes, vaginal discharge, vaginal dryness or pain, or abnormal bleeding. Men: Denies scrotal pain, penis pain, masses, weak stream or erectile dysfunction
MUSCULOSKELETAL: denies stiffness, joint pain, joint swelling, muscle pain, or decreased ROM.
INTEGUMENTARY/BREAST: Denies pruritus, rashes, stria, lesions, wounds, nodules, tumors, eczema, excessive dryness and/or discoloration. Denies breast pain, soreness, lumps, or discharge.
NEURO: denies seizures, headaches, motor weakness, paresthesias, paralysis, memory loss
PSYCH: denies anxiety, depression, mood changes, body image problems, mania, binges, or suicidal thoughts
ENDOCRINE: Denies heat or cold intolerance, weight changes, polyuria, polydipsia, polyphagia, changes in hair, libido or sexual performance
HEMATOLOGIC/LYMPHATIC: Denies excessive bleeding, easy bruising, petechia. Denies enlarged, swollen, or tender lymph nodes
ALLERGY/IMMUNOLOGY: Denies drug/food/seasonal allergies, denies getting sick more frequently than others, or taking longer to recover
OBJECTIVE:
VITAL SIGNS: P: BP: RR: T: 97.8 SpO2 RA: Pain : /10
Ht : Wt : BMI:
PHYSICAL EXAM:
GENERAL survey:
HEENT:
Head
Eyes
Ears
Nose
Throat
Mouth
·
HEART:
RESPIRATORY:
CHEST/BREASTS:
GI:
GU:
LYMPH:
MUSCULOSKELETAL/EXTREMITIES:
SKIN:
NEUROLOGIC:
PSYCHIATRIC:
ASSESSMENT:
Differential Diagnosis:
1.
One possible dx with rationale on why you ruled out
2.
Another
3.
A third (minimum = three)
4.
A fourth
FINAL DX: The chosen diagnosis from above
PLAN:
-Diagnostic plan (labs/xrays/EKG etc.)
-Treatment/Therapeutic Plan: Meds, treatments, diet/exercise/etc. recommendation
-Referrals
-Education
-F/U plan
Select a patient. You may use a peer, friend, or family for this assignment, but they must be 18 or older.
Obtain a complete health history from this “patient”
Have the patient pretend they are visiting you for
a “well exam” or
“annual check up” (as opposed to a problem focus) and use the health history template posted in the course.
DO NOT perform any physical exam. You are only doing the
interview portion of the patient visit for this assignment.
Document your findings as you would for a comprehensive visit, including a risk assessment
(at least 3 health risks for example high cholesterol, high blood pressure, high blood sugar, low vitamin D….. any health risk
with rationale)You can be creative in your assessment.
Submit this partial SOAP note (NO Objective section – NO exam) of the history and risk assessment via the assignment tab.
Expectations
· APA format with intext citations
·
Word count minimum of 500, not including references.
· References: 2 high-level scholarly references within the last 5 years in APA format.
· Plagiarism free.
· Turnitin receipt.
SOAP note template
SOAP
SUBJECTIVE:
ID:
CC: “ “
HISTORY OF PRESENT ILLNESS (HPI):
PAST MEDICAL HISTORY
PAST MEDICAL PROCEDURES
MEDICATIONS
ALLERGIES
LMP (as applies)
FAMILY HISTORY
SOCIAL HISTORY
-SEXUAL/REPRODUCTIVE
-TOBACCO USE/Vaping:
-ALCOHOL USE: social drinker
-DRUG USE:
-MARITAL HISTORY:
-OCCUPATION:
-EXERCISE/DIET:
-SLEEP/STRESS:
IMMUNIZATIONS
SPIRITUAL AFFILIATION
REVIEW OF SYSTEMS:
ONLY DOCUMENT WHAT YOU ASKED ABOUT
DO NOT copy and paste this list or you will have a high “Turn-It-In” score. Students should be able to reword and include only what they asked.
CONSTITUTIONAL: denies fever, chills, and loss of appetite, fatigue, or weight loss
EYES: denies blurred vision, scleral icterus, tunnel vision, discharge, pruritus, edema, and redness (date of last eye exam can go here)
EARS, NOSE, MOUTH/THROAT: denies hearing loss, tinnitus, vertigo, discharge, and earache, denies rhinorrhea, stuffiness, sneezing, and epistaxis, denies allergies, denies pain or difficulty swallowing (date of last dental exam can go here)
CARDIOVASCULAR: denies angina, palpitations, orthopnea, paroxysmal nocturnal dyspnea, edema, or dyspnea.
RESPIRATORY: Denies hemoptysis, wheezing, and shortness of breath, cough, or sputum production.
GASTROINTESTINAL: denies, dysphagia, constipation, abdominal pain, hemorrhoids. Reports rectal bleeding with bright red blood, rectal pain, and reflux and history of rectal cancer.
GENITOURINARY: denies urinary urgency, hesitancy, frequency, polyuria, dysuria, hematuria, incontinence, libido changes, and infection. Women: Denies menstrual changes, vaginal discharge, vaginal dryness or pain, or abnormal bleeding. Men: Denies scrotal pain, penis pain, masses, weak stream or erectile dysfunction
MUSCULOSKELETAL: denies stiffness, joint pain, joint swelling, muscle pain, or decreased ROM.
INTEGUMENTARY/BREAST: Denies pruritus, rashes, stria, lesions, wounds, nodules, tumors, eczema, excessive dryness and/or discoloration. Denies breast pain, soreness, lumps, or discharge.
NEURO: denies seizures, headaches, motor weakness, paresthesias, paralysis, memory loss
PSYCH: denies anxiety, depression, mood changes, body image problems, mania, binges, or suicidal thoughts
ENDOCRINE: Denies heat or cold intolerance, weight changes, polyuria, polydipsia, polyphagia, changes in hair, libido or sexual performance
HEMATOLOGIC/LYMPHATIC: Denies excessive bleeding, easy bruising, petechia. Denies enlarged, swollen, or tender lymph nodes
ALLERGY/IMMUNOLOGY: Denies drug/food/seasonal allergies, denies getting sick more frequently than others, or taking longer to recover
OBJECTIVE:
VITAL SIGNS: P: BP: RR: T: 97.8 SpO2 RA: Pain : /10
Ht : Wt : BMI:
PHYSICAL EXAM:
GENERAL survey:
HEENT:
Head
Eyes
Ears
Nose
Throat
Mouth
·
HEART:
RESPIRATORY:
CHEST/BREASTS:
GI:
GU:
LYMPH:
MUSCULOSKELETAL/EXTREMITIES:
SKIN:
NEUROLOGIC:
PSYCHIATRIC:
ASSESSMENT:
Differential Diagnosis:
1.
One possible dx with rationale on why you ruled out
2.
Another
3.
A third (minimum = three)
4.
A fourth
FINAL DX: The chosen diagnosis from above
PLAN:
-Diagnostic plan (labs/xrays/EKG etc.)
-Treatment/Therapeutic Plan: Meds, treatments, diet/exercise/etc. recommendation
-Referrals
-Education
-F/U plan
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