Nursing work

Soapnotesrubric11 xReferences11 x

This assignment will be graded according to the rubric. Please have the Rubric handy when you are writing the soap note.

 

soap note please follow the rubric. please need a turnitin report

  need to write a thorough Review of Systems (ROS), and a thorough physical examination. 

Chief Complaint: “I fell down in my house a week ago and my knee is still hurting”.

History of Present Illness: Mr. Brown is 45-year-old male teacher who presents to the clinic with symptoms of right knee pain related to a fall sustained at home one week ago while he was coming down the stairs. Patient states that he tripped and during the fall, the right knee twisted and was caught between two bars of the stair wells. Immediately after the fall, the pain was sharp and stabbing, and he was unable to walk straight and apply weight on the knee. He applied ice and took 800mg of Motrin and went to bed. Patient states he did not want to go to the emergency department because of the long wait. After 24 hours he applied warm compresses intermittently and took extra strength Tylenol as needed. Mitigating factors include ES Tylenol, heat application, and resting the knee. However, sometimes the pain is so severe that even Tylenol does not help. Aggravating factors are standing too long, bending the knee, and climbing stairs. He describes the pain as sharp, and annoying at the same time. At present time he feels like “something is not right inside the knee”. Level of pain is 8/10. He denies previous musculoskeletal injuries. Patient also reports shortness of breath but denies chest pain. 

PMH: Asthma, bipolar disorder. Left knee anterior crucial ligament (ACL) 10 years ago from basketball injury.

Past surgical history: Right hip replacement 15 years ago from kick boxing.

Medications

/OTC: Theophylline, Prednisone, Singular, Geodon, Prozac, Benadryl.

Allergies: NKA.

Past family history: One brother with asthma, and another brother with bipolar. Maternal aunt with DM type II.

Health Maintenance: Immunization up to date.

Social history: Patient does not smoke, drink or use recreational drugs. He maintains a regular diet and exercises 3 times a week. He has been married for 10 years and lives with his wife and one adult son, and one teenage daughter. He is a mathematics teacher in the same high school where he attends clinic. He sleeps well.

With the information provided above, please continue the patient’s soap note to include:

Subjective: A thorough review of systems

Objective: A thorough physical examination

Primary diagnosis

3 differential diagnosis with one citation for each ddx (APA formatted).

Laboratory tests

Diagnostic testing

Management plan

Medications

Non-pharmacological approach

Follow up

Patient education and Health promotion

References: A minimum of 3 different references are required for this assignment. All references must be properly APA formatted.

This assignment will be graded according to the rubric. Please have the Rubric handy when you are writing the soap note.

SOAP NOTE RUBRIC

5

10

5

5

3

1

10

10

8

6

5

5

3

1

10

10

8

6

10

10

8

6

20

5

5

3

1

5

5

3

1

5

5

3

1

5

5

3

1

5

5

3

1

Criteria

Points

Competent

Need Improvement

Not Acceptable

Score

Subjective (35 points)

Provides complete, concise, and accurate information which is well organized and easy to understand.

Provides most of the pertinent information but is not well organized and/or is slightly challenging to understand. May be missing pertinent negative information (e.g., patient denies…).

Limited or no summary of pertinent information, is organized poorly, contains inaccurate information, and/or is difficult to understand.

Chief complaint

5

3

1

HPI

10

8

6

Relevant PMH & FH

ROS

Currents: Allergies, Meds/OTCs, Tobacco, Immunizations, Diet, Exercise, Sleep

Objective (40 points)

Provides complete, concise, and accurate information which is well organized and easy to understand.

Provides most of the pertinent information but is not well organized and/or is slightly challenging to understand. May be missing pertinent negative information (e.g., patient denies)

Limited or no summary of pertinent information, is organized poorly, contains inaccurate information, and/or is difficult to understand.

General survey (Describe the state of the patient at the time of the examination)

Vital signs, wt., BMI

Physical exam-systematic, organized and thorough and related to the reason of the visit

20

18

16

Diagnosis/ Differentials Diagnosis (10 points)

Main diagnosis/ Differentials Diagnosis is supported by the objective and subjective assessment and rationale for choosing the diagnosis is supported by the evidence

Main diagnosis/ Differentials Diagnosis is supported by the objective and subjective assessment but the rationale for choosing the diagnosis is not supported by the evidence

Main diagnosis/ Differentials Diagnosis is not supported by the objective and subjective assessment and the rationale for choosing the diagnosis is not supported by the evidence

Diagnosis/ (Assessment)

List of differentials supported by S+O findings (5 points) Must provide 3 differential diagnoses with one citation for each diagnosis.

Plan of care (10 Points)

Complete and appropriate plan for the main problem and other active problems. Includes pharmacologic and/or non-pharmacologic and/or complete sig components.

Mostly complete and appropriate plan for the main problem and other active problems. May be missing appropriate non-pharmacologic treatments and/or sig components.

Missing or inappropriate treatment plan for the main problem and other active problems.

Diagnostic tests/therapies/medications

Follow-up/Pt. Education and Health Promotion

References (5 Points)

Provides a complete and appropriate list of references that are in APA format.

References listed are appropriate (i.e. guidelines or primary), but not complete and some may be missing. Not APA formatted.

References missing or very limited. References listed are inappropriate (i.e. tertiary) and/or not relevant.

References

Total

100

Comment:

Below is how an example of how a reference list looks like:

References

American Lung Association. (2009). Chronic obstructive pulmonary disease (COPD) fact sheet.

Retrieved on March 8, 2013, from

http://www.lung.org/lung-

disease/copd/resources/facts-figures/COPD-Fact-Sheet.html

American Lung Association. (2010). The promise of research. Retrieved on March 12, 2013,

from

http://www.lung.org/finding-cures/research-news/promise-of-research/por-fall-

2010/promise-of-research-fall2010

Buttaro, T. M., Trybulski, J., Bailey, P. P., & Sandberg-Cook, J. (2012). Primary care: a

collaborative practice. St. Louis, Mo.: Elsevier/Mosby.

Durairaj, L. (2010). Disparities in lung disease: Ethnic & racial clues. Retrieved on March 7,

2013, from

http://www.lung.org/assets/documents/publications/research-

awardsnationwide/RAN0405_LR

Miravitlles, M. et al. (2010). Cost of chronic bronchitis and copd: 1-year follow-up study.

Retrieved on March 8, 2013, from https://journal.publications.chestnet.org/data/Journals/CHEST/21990/784

National Guideline Clearinghouse. (2010). Management of uncomplicated acute bronchitis in

adults. Retrieved on March7, 2013, from

http://www.lung.org/finding-cures/research-news/promise-of-research/past-issues/por-spr

Niederman, M., S. et al. (2012). Treatment cost of acute exacerbations of chronic bronchitis.

Retrieved on March 11, 2013, http://www.ncbi.nlm.nih.gov/pubmed/10321424

Poole P, H. (2012). Prophylactic antibiotic therapy for chronic bronchitis and chronic

obstructive pulmonary disease (COPD) (Protocol), Retrieved on March 11, 2013, from http://onlinelibrary.wiley.com/doi/10.1002/14651858.CD009764/pdf

South Carolina Department of Health and Environmental Control. (2010). Identification and

elimination of health disparities among populations. Retrieved on March 8, 2013, from http://www.scdhec.gov/health/chcdp/tobacco/goal4.htm

Thomas, M. (2012). Acute bronchitis in adults. Retrieved on March 2, 2013, from

http://www.uptodate.com/contents/acute-bronchitis-in-

adults?source=search_result&search=bronchitis&selectedTitle=1%7E150