SOAP NOTE WEEK 7

see attached template

Patient is 44 y/o female with BV

Specifics r/t BMI and BP and assessment findings can be whatever.  Please ensure proper diagnosis, treatment and assessment findings are appropriate

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Fo

Use the topic proposal that is attached and finish the paper including a: bibliography page that follows the instructions below and follows the original thesis: Is face transplantation considered medically ethical and personally mora.

Annotated Bibliography: must meet the following requirements:

  • MLA Format;
  • Catalog 5 peer-reviewed, academic sources from the Mary and John Gray Library;
  • Each source should be accompanied by a 150 word annotation;
  • Bibliography must be well-organized and easy to read;
  • Information must be communicated clearly and succinctly.

Rough Draft:

You must also attach a well-developed rough draft of your final essay.

 MLA format 

  • 700-900 words
  • minimum of four paragraphs
  • written in 3rd person
  • minimum 80% original work (this means your paper cannot be dominated by quotes from your sources)
  • minimum of five academic sources with in-text citations for each source
  • a Works Cited page with entries for each source included in the paper
    • academic sources must include peer-reviewed journal articles from the Lamar University Online Library or other approved sources
    • Your annotated bibliography should NOT be attached to your final draft.
  • Assignment must be submitted as a Word doc. Any other format will not be accepted for credit.

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Nurse Practitioner

To Prepare:

  • Review the Career Planner Guide.
  • Seek out resources on cover letters, resumes, and other professional resources, as needed. 
  • Develop a cover letter, resume, philosophy statement, and other professional resources that meet the requirements outlined in the Career Planner Guide.

I have attached the job I would be applying for, the career planner guide to go by and a copy of my professional experiences which includes my education, certifications and awards for the resume and other items if needed. I added some information just to give you an idea of the type of job it was. Don’t feel obligated to use what I provided, it was for information purposes only.

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N/A

46-year-old Caucasian female with complaints of pain to right shoulder. She states she was carrying a grill up her stairs when the grill began to fall. She states she did not hit her shoulder but was also drug down the steps with the grill. She states the pian is 10/10 if she moves her right arm and radiates to her neck. She reports the pain is 6/10 if she remains still. Shoulder x-ray in office reveals no abnormalities. Patient referred to orthopedic for further evaluation.

 

BP 132/78, HR 88, Respirations 18, Ht 5 ft 6 in., Weight 182

History of HTN treated with Amlodipine 5mg daily

Feel free to make up additional information

 

·  Review the Comprehensive SOAP Note Template.

·  With this patient in mind, consider the following: 

  • Subjective: What details did the patient provide regarding the personal and medical history?
  • Objective: What observations did you make during the physical assessment? Include pertinent positive and negative physical exam findings. Describe whether the patient presented with any morbidities and psychosocial issues.
  • Assessment: What were your differential diagnoses? Provide a minimum of three possible diagnoses. List them from highest priority to lowest priority and include their CPT and ICD-10 codes for the diagnosis. What was your primary diagnosis and why? Provide at least 4 scholarly articles as references. No older than 5 years
  • Plan: What was your plan for diagnostics and primary diagnosis? What was your plan for treatment and management? Include pharmacologic and non-pharmacologic treatments, alternative therapies, and follow-up parameters, as well as a rationale for this treatment and management plan. Provide at least 2 scholarly articles as references no older than 5 years
  • Reflection notes: What was your “aha” moment? What would you do differently in a similar patient evaluation?

 

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