Please review the complete instructions on attached document. Use the provided template to complete the assignment
Episodic/Focused SOAP Note Template
Patient Information:
Initials, Age, Sex, Race
S.
CC (chief complaint) a BRIEF statement identifying why the patient is here – in the patient’s own words – for instance “headache”, NOT “bad headache for 3 days”.
HPI: This is the symptom analysis section of your note. Thorough documentation in this section is essential for patient care, coding, and billing analysis. Paint a picture of what is wrong with the patient. Use LOCATES Mnemonic to complete your HPI. You need to start EVERY HPI with age, race, and gender (e.g., 34-year-old AA male). You must include the seven attributes of each principal symptom in paragraph form not a list. If the CC was “headache”, the LOCATES for the HPI might look like the following example:
Location: head
Onset: 3 days ago
Character: pounding, pressure around the eyes and temples
Associated signs and symptoms: nausea, vomiting, photophobia, phonophobia
Timing: after being on the computer all day at work
Exacerbating/ relieving factors: light bothers eyes, Aleve makes it tolerable but not completely better
Severity: 7/10 pain scale
Current Medications: include dosage, frequency, length of time used and reason for use; also include OTC or homeopathic products.
Allergies: include medication, food, and environmental allergies separately (a description of what the allergy is ie angioedema, anaphylaxis, etc. This will help determine a true reaction vs intolerance).
PMHx: include immunization status (note date of last tetanus for all adults), past major illnesses and surgeries. Depending on the CC, more info is sometimes needed
Soc Hx: include occupation and major hobbies, family status, tobacco & alcohol use (previous and current use), any other pertinent data. Always add some health promo question here – such as whether they use seat belts all the time or whether they have working smoke detectors in the house, living environment, text/cell phone use while driving, and support system.
Fam Hx: illnesses with possible genetic predisposition, contagious or chronic illnesses. Reason for death of any deceased first degree relatives should be included. Include parents, grandparents, siblings, and children. Include grandchildren if pertinent.
ROS: cover all body systems that may help you include or rule out a differential diagnosis You should list each system as follows: General: Head: EENT: etc. You should list these in bullet format and document the systems in order from head to toe.
Example of Complete ROS:
GENERAL: Denies weight loss, fever, chills, weakness or fatigue.
HEENT: Eyes: Denies visual loss, blurred vision, double vision or yellow sclerae. Ears, Nose, Throat: Denies hearing
**THIS DISCUSSION IS DIVIDE IN TWO PARTS –
1. MAIN DISCUSSION POST BY WEDNESDAY 10/20/2021 BEFORE 8:00 PM EST
2. TWO REPLIES BY FRIDAY 10/22/2021 BEFORE 8:00 PM EST
Discussion: Assessing Musculoskeletal Pain
The body is constantly sending signals about its health. One of the most easily recognized signals is pain. Musculoskeletal conditions comprise one of the leading causes of severe long-term pain in patients. The musculoskeletal system is an elaborate system of interconnected levers that provides the body with support and mobility. Because of the interconnectedness of the musculoskeletal system, identifying the causes of pain can be challenging. Accurately interpreting the cause of musculoskeletal pain requires an assessment process informed by patient history and physical exams.
In this Discussion, you will consider a case study that describe abnormal findings in patients seen in a clinical setting.
Case Study 1: Back Pain
A 42-year-old male reports pain in his lower back for the past month. The pain sometimes radiates to his left leg. In determining the cause of the back pain, based on your knowledge of anatomy, what nerve roots might be involved? How would you test for each of them? What other symptoms need to be explored? What are your differential diagnoses for acute low back pain? Consider the possible origins using the Agency for Healthcare Research and Quality (AHRQ) guidelines as a framework. What physical examination will you perform? What special maneuvers will you perform?
To prepare:
· Your Discussion post should be in the Episodic/Focused SOAP Note format rather than the traditional narrative style Discussion posting format. Remember that all Episodic/Focused SOAP notes have specific data included in every patient case. Please use attached template
· Consider what history would be necessary to collect from the patient in the case study you were assigned.
· Consider what physical exams and diagnostic tests would be appropriate to gather more information about the patient’s condition. How would the results be used to make a diagnosis?
Discussion Instructions
1. Post an episodic/focused note about the patient in the case study using the episodic/focused note template. (See attached document – template)
2. Provide evidence from the literature to support diagnostic tests that would be appropriate for each case.
3. List five different possible conditions for the patient’s differential diagnosis and justify why you selected each.
**THIS DISCUSSION IS DIVIDE IN TWO PARTS
–
1
Instructions:
· Respond to your colleague who was assigned a different case study than yours.
· Analyze the possible conditions from your colleagues’ differential diagnoses.
· Determine which of the conditions you would reject and why.
· Identify the most likely condition, and justify your reasoning.
**minimum of three (3) scholarly references are required for each reply cited within the body of the reply & at the end**
Reply # 1
Episodic/Focused SOAP Note: Ankle Pain
Patient Information:
A.J., 46 years old, F, Wht
S.
CC: “Ankle pain”
HPI: AJ is a pleasant, 46-year-old, white female with a complaint of ankle pain. She reports pain in both of her ankles, but the pain in the right ankle is more severe. She was playing soccer over the weekend and heard a “pop”. She is able to bear weight on both ankles but is uncomfortable. She reports the pain in her left ankle as a 3 and the pain in her right ankle as a 9 on a scale to 1-10. She reports the pain as an aching and throbbing sensation. She reports temporary relief with ice and elevation; however, the pain is aggravated when she walks or touches it. She has not taken any over-the-counter medications for the ankle pain. She is more concerned about the constant pain in her right ankle. She denies having fevers, nausea, and vomiting.
Current Medications:
Multivitamin Tablet Once Daily (last dose this morning)
Ibuprofen 400mg Every 6 Hours as needed for pain (last dose two weeks ago)
Allergies: No Known Allergies
PMHx: Influenza Vaccine (October 2021)
Soc Hx: AJ is a soccer teacher at her community recreational center for middle school girls. She denies alcohol use, and never smoked. She denies use of marijuana or illicit drugs. She maintains a healthy lifestyle by exercising 5 days a week: alternating riding her bicycle and swimming. She is married and has 15-year-old twin daughters. She has a strong support system consisting of her family and her next-door neighbors.
Fam Hx: Mother is alive age 78, Hx: Osteoarthritis, Gout. Father deceased at age 56 from motor vehicle accident, had no medical history or musculoskeletal disorders. Grandparents’ medical history not known. Brother, age 35, no medical history. Daughters, identical twins aged 15 diagnosed with asthma at age 5.
ROS:
GENERAL: No weight loss, fever, chills, weakness, or fatigue
SKIN: Skin intact. No tenting. No rashes. No lesions. No discoloration. Swelling in right ankle.
CARDIOVASCULAR: No chest pain, chest pressure or chest discomfort. No palpitations or edema.
RESPIRATORY: No shortness of breath, cough, or sputum.
NEUROLOGICAL: No headache, dizziness, syncope, paralysis,
Instructions:
· Respond to your colleague who was assigned a different case study than yours.
· Analyze the possible conditions from your colleagues’ differential diagnoses.
· Determine which of the conditions you would reject and why.
· Identify the most likely condition, and justify your reasoning.
**minimum of three (3) scholarly references are required for each reply cited within the body of the reply & at the end**
Reply # 2
Episodic/Focused SOAP Note Template
Patient Information:
I. T. , 15 y/o, M, AA
S.
CC: “I been having a dull like achy pain in both my knees and sometimes I feel a catching feeling in either one knee or sometimes both”.
HPI: I. T. 15 y/o, AA, male patient who presents to clinic today with complaints of bilateral knee pain for the past 7 days that is described as a dull pain which is a 6/10 pain. The pain is at times accompanied by a “clicking” noise and catching sensation under his patella. It is exacerbated by physical activity such as running and is aggravated more with basketball practice. He reports ibuprofen and rest alleviates the pain.
Current Medications: Ibuprofen 500mg as needed for knee pain. Daily vitamins. Adderall 25mg daily in the morning.
Allergies: Penicillin- hives.
PMHx: UTD on vaccines. History of patellar dislocation, Tonsillectomy 2019.
Soc Hx: I.T. non-sexually active teen who lives with mother, parents divorced, has visitation with his father on weekends. Denies tobacco use, illicit drugs, or alcohol use. Reports wearing seat belt at all times when in car. He participates in extra curriculum activities basketball and tutoring. He enjoys time with his friends and playing video games. Sleeps 8-9 hours at night.
Fam Hx: Both parents still living. Mother-39 y/o, hx of depression, Father-37 y/o, arthritis, hypertension, Sister-5 y/o no significant history.
ROS:
GENERAL: Denies weight loss, or gain, no change in appetite, denies fever, chills, or fatigue.
HEENT: No blurred vision, no loss of hearing, or ringing in ears, denies runny nose, congestion and sore throat, no swelling or tenderness of lymph nodes.
SKIN: Denies rash or itching and lesions.
CARDIOVASCULAR: Denies chest pain, chest pressure or chest discomfort. No palpitations or edema.
RESPIRATORY: Denies shortness of breath, or cough.
GASTROINTESTINAL: Denies nausea, vomiting or diarrhea. No abdominal pain.
GENITOURINARY: Denies any difficulty in urinating or burning.
NEUROLOGICAL: Denies headache, dizziness, numbness or tingling in the extremities.
MUSCULOSKELETAL: Reports pain to bilateral knees, pain with knee extension and tenderness.
HEMATOLOGIC: Denie
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