\u00a0\u00a0
\nChoose one skin condition graphic Shingles # 5 \u00a0(identify by number in your Chief Complaint) to document your assignment in the SOAP (Subjective, Objective, Assessment, and Plan) note format rather than the traditional narrative style. Refer to the Comprehensive SOAP Template (see below template). Remember that not all comprehensive SOAP data are included in every patient case.
\nUse clinical terminologies to explain the physical characteristics featured in the graphic. Formulate a differential diagnosis of three to five possible conditions for the skin graphic that you chose. Determine which is most likely to be the correct diagnosis and explain your reasoning using at least three different references, one reference from current evidence-based literature from your search and two different references from \u00a0Learning Resources.<\/p>\n
#5 Shingles
\nComprehensive SOAP Template
\nPatient Initials: _______ Age: _______ Gender: _______
\nNote: The mnemonic below is included for your reference and should be removed before the submission of your final note.
\nO = onset of symptom (acute\/gradual)
\nL= location\u00a0
\nD= duration (recent\/chronic)
\nC= character
\nA= associated symptoms\/aggravating factors
\nR= relieving factors
\nT= treatments previously tried \u2013 response? Why discontinued?
\nS= severity
\nSUBJECTIVE DATA: Include what the patient tells you, but organize the information.
\nChief Complaint (CC): In just a few words, explain why the patient came to the clinic.
\nHistory of Present Illness (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. You need to start EVERY HPI with age, race, and gender (i.e. 34-year-old AA male). You must include the 7 attributes of each principal symptom:
\n1. Location
\n2. Quality
\n3. Quantity or severity
\n4. Timing, including onset, duration, and frequency
\n5. Setting in which it occurs
\n6. Factors that have aggravated or relieved the symptom
\n7. Associated manifestations
\nMedications: Include over the counter, vitamin, and herbal supplements. List each one by name with dosage and frequency.
\nAllergies: Include specific reactions to medications, foods, insects, and environmental factors.
\nPast Medical History (PMH): Include illnesses (also childhood illnesses), hospitalizations, and risky sexual behaviors.
\nPast Surgical History (PSH): Include dates, indications, and types of operations.
\nSexual\/Reproductive History: If applicable, include obstetric history, menstrual history, methods of contraception, and sexual function.
\nPersonal\/Social History: Include tobacco use, alcohol use, drug use, patient\u2019s interests, ADL\u2019s and IADL\u2019s if applicable, and exercise and eating habits.
\nImmunization History: Include last Tdp, Flu, pneumonia, etc.
\nSignificant Family History: Include history of parents, Grandparents, siblings, and children.
\nLifestyle: Include cultural factors, economic factors, safety, and support systems.
\nReview of Systems: From head-to-toe, include each system that covers the Chief Complaint, History of Present Illness, and History (this includes the systems that address any previous diagnoses). Remember that the information you include in this section is based on what the patient tells you. You do not need to do them all unless you are doing a total H&P. To ensure that you include all essentials in your case, refer to Chapter 2 of the Sullivan text.
\nGeneral: Include any recent weight changes, weakness, fatigue, or fever, but do not restate HPI data here.
\nHEENT:
\nNeck:
\nBreasts:
\nRespiratory:
\nCardiovascular\/Peripheral Vascular:
\nGastrointestinal:
\nGenitourinary:
\nMusculoskeletal:
\nPsychiatric:
\nNeurological:
\nSkin: Include rashes, lumps, sores, itching, dryness, changes, etc.
\nHematologic:
\nEndocrine:
\nAllergic\/Immunologic:
\nOBJECTIVE DATA: From head-to-toe, include what you see, hear, and feel when doing your physical exam. You only need to examine the systems that are pertinent to the CC, HPI, and History unless you are doing a total H&P. Do not use WNL or normal. You must describe what you see.
\nPhysical Exam:
\nVital signs: Include vital signs, ht, wt, and BMI.
\nGeneral: Include general state of health, posture, motor activity, and gait. This may also include dress, grooming, hygiene, odors of body or breath, facial expression, manner, level of conscience, and affect and reactions to people and things.\u00a0
\nHEENT:
\nNeck:
\nChest\/Lungs: Always include this in your PE.
\nHeart\/Peripheral Vascular: Always include the heart in your PE.
\nAbdomen:
\nGenital\/Rectal:
\nMusculoskeletal:
\nNeurological:
\nSkin:
\nASSESSMENT: List your priority diagnosis(es). For each priority diagnosis, list at least 3 differential diagnoses, each of which must be supported with evidence and guidelines. Include any labs, x-rays, or other diagnostics that are needed to develop the differential diagnoses. For holistic care, you need to include previous diagnoses and indicate whether these are controlled or not controlled. These should also be included in your treatment plan.
\nPLAN: This section is not required for the assignments in this course (NURS 6512), but will be required for future courses.
\nTreatment Plan: If applicable, include both pharmacological and nonpharmacological strategies, alternative therapies, follow-up recommendations, referrals, consultations, and any additional labs, x-ray, or other diagnostics. Support the treatment plan with evidence and guidelines.
\nHealth Promotion: Include exercise, diet, and safety recommendations, as well as any other health promotion strategies for the patient\/family. Support the health promotion recommendations and strategies with evidence and guidelines.
\nDisease Prevention: As appropriate for the patient\u2019s age, include disease prevention recommendations and strategies such as fasting lipid profile, mammography, colonoscopy, immunizations, etc. Support the disease prevention recommendations and strategies with evidence and guidelines.
\nREFLECTION: Reflect on your clinical experience and consider the following questions: What did you learn from this experience? What would you do differently? Do you agree with your preceptor based on the evidence?\u00a0
\n3 References<\/p>\n","protected":false},"excerpt":{"rendered":"
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