episodic soap note

45 year old male (L.R) that presented to the local clinic for difficulty starting urination, no signs or symptoms of burning or discomfort otherwise, and patient was concerned that he presented with inability to fully empty his bladder at times.       

Medications:    

 1 tablet Centrum Multivitamin Daily .  Protonix 20mg PO daily for GERD.    

 

 

These findings, describe abnormal findings and as a provider develop an episodic note and you are allowed to make up vital signs and related body systems areas for the SOAP note.           

 

o Identify at least five possible conditions that may be considered in a differential diagnosis for the Consider what history would be necessary to collect from the patient in the case study.  

o 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?  

o Identify at least five possible conditions that may be considered in a differential diagnosis for the patient.  

 

 

 

The Assignment

Using evidence-based resources from your search, answer the following questions and support your answers using current evidence from the literature.

  • Analyze the subjective portion of the note. List additional information that should be included in the documentation.
  • Analyze the objective portion of the note. List additional information that should be included in the documentation.
  • Is the assessment supported by the subjective and objective information? Why or why not?
  • Would diagnostics be appropriate for this case, and how would the results be used to make a diagnosis?
  • Would you reject/accept the current diagnosis? Why or why not? Identify three possible conditions that may be considered as a differential diagnosis for this patient. Explain your reasoning using at least three different references from current evidence-based literature.

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