Advanced Health Assessment and Diagnostic Reasoning Template

1. Week 9 Case Study Assignment This week there are 3 case studies. You are writing and submitting a comprehensive SOAP note. Be sure to follow the SOAP template and rubric to assure that you are completing the assignment correctly. The assignments for this week are as follows:

Case Study #1- Last name A-K

20-year-old male complains of experiencing intermittent headaches. The headaches diffuse all over the head, but the greatest intensity and pressure occurs above the eyes and spreads through the nose, cheekbones, and jaw. Advanced Health Assessment and Diagnostic Reasoning Template

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Case Study #2- Last name L-R

47-year-old obese female complains of pain in her right wrist, with tingling and numbness in the thumb and index and middle fingers for the past 2 weeks. She has been frustrated because the pain causes her to drop her hair-styling tools

Case Study #3- Last name S-Z

33-year-old female comes to your clinic alarmed about sudden “drooping” on the right side of the face that began this morning. She complains of excessive tearing and drooling on her right side as well. Advanced Health Assessment and Diagnostic Reasoning Template

case study #1 needs to be done.

Comprehensive SOAP Template Patient Initials: _______ Age: _______ Gender: _______ Note: The mnemonic below is included for your reference and should be removed before the submission of your final note. O = onset of symptom (acute/gradual) L= location D= duration (recent/chronic) C= character A= associated symptoms/aggravating factors R= relieving factors T= treatments previously tried – response? Why discontinued? S= severity SUBJECTIVE DATA: Include what the patient tells you, but organize the information. Chief Complaint (CC): In just a few words, explain why the patient came to the clinic. History 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: 1. Location 2. Quality 3. Quantity or severity 4. Timing, including onset, duration, and frequency 5. Setting in which it occurs 6. Factors that have aggravated or relieved the symptom 7. Associated manifestations Medications: Include over the counter, vitamin, and herbal supplements. List each one by name with dosage and frequency. Allergies: Include specific reactions to medications, foods, insects, and environmental factors. Past Medical History (PMH): Advanced Health Assessment and Diagnostic Reasoning Template

Include illnesses (also childhood illnesses), hospitalizations, and risky sexual behaviors. Past Surgical History (PSH): Include dates, indications, and types of operations. © 2019 Walden University Page 1 of 3 Sexual/Reproductive History: If applicable, include obstetric history, menstrual history, methods of contraception, and sexual function. Personal/Social History: Include tobacco use, alcohol use, drug use, patient’s interests, ADL’s and IADL’s if applicable, and exercise and eating habits. Immunization History: Include last Tdp, Flu, pneumonia, etc. Significant Family History: Include history of parents, Grandparents, siblings, and children. Lifestyle: Include cultural factors, economic factors, safety, and support systems. Review 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. General: Include any recent weight changes, weakness, fatigue, or fever, but do not restate HPI data here. HEENT: Neck: Breasts: Respiratory: Cardiovascular/Peripheral Vascular: Gastrointestinal: Genitourinary: Musculoskeletal: Psychiatric: Neurological: Skin: Include rashes, lumps, sores, itching, dryness, changes, etc. Hematologic: Endocrine: Allergic/Immunologic: OBJECTIVE 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. Physical Exam: Vital signs: Include vital signs, ht, wt, and BMI. © 2019 Walden University Page 2 of 3 General: 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. HEENT: Neck: Chest/Lungs: Always include this in your PE. Heart/Peripheral Vascular: Always include the heart in your PE. Abdomen: Genital/Rectal: Musculoskeletal: Neurological: Skin: ASSESSMENT: 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. PLAN: Advanced Health Assessment and Diagnostic Reasoning Template

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This section is not required for the assignments in this course (NURS 6512), but will be required for future courses. Treatment 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. Health 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. Disease Prevention: As appropriate for the patient’s 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. REFLECTION: 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? Advanced Health Assessment and Diagnostic Reasoning Template