WEEK 6 SPOAP NOTE
Order Instructions
Hello, I am attaching a sample paper you will find in the first file titled” NRNP WEEK 6 CASE STUDY” please use it and do the same assignment, review it properly to minimize plagiarism. Make sure you also review the second file with the instructions and rubric
For the Diagnosis it should be like this:
1. Community Acquired Pneumonia
2. Myocardial Infarction- I21.9
3. Contact with and (suspected) exposure to COVID-19- Z20.822:
4. Acute bronchitis- J20.9
Note that Community Acquired Pneumonia is the main diagnosis and carefully do all necessary things included in the plan as this area is going for a greater point.
Below is the assignment scenario and is the same as the attached paper:
.:
Use the following case to complete a focused SOAP note
Edwin is a 69-year-old male who comes into the clinic today stating that over the past few days, he has had a fever and chills, cough, and has been quite fatigued. He didn’t take his temperature because he did not have a thermometer but he “felt hot.” He says he is coughing up a little phlegm. He states that it hurts when he takes a deep breath. He also states that his appetite has not been very good. He has been taking Tylenol with minimal relief. He has also been drinking teas to try to break up the phlegm.
Edwin is a nonsmoker and non-drinker. He has been very healthy and has no medical problems. He has never had surgery.
On exam, his vital signs are: BP 130/80; P 84; R 14; T 103.2; Pulse ox: 94%.
Exam reveals decreased rales and rhonchi, more pronounced in the left lower lung fields, with increased fremitus and dullness to percussion. Chest x-ray reveals a consolidation in the left lower lobe. This appears to confirm that he has pneumonia.
For this SOAP note, please state the question and provide the answer at the end of your SOAP note. I suggest that you do not try to incorporate the answer into the note, but rather answer the question in question/answer format.
1. Which bacteria is the leading cause of pneumonia and the one that he most likely has?
2. What is unusual about this pts history as compared to most pts that are at risk for s.pneumoniae?
3. In this type of pneumonia, does the sputum analysis indicate gram positive or negative diplococci? There would also be a large number of ________
4. What other bacteria must be considered?
5. What is the best way to identify the pathologic agent?
6. Where does the best sputum sample come from?
7. When is the best time to get a sputum sample? Why is that the best time?
8. When sending the sputum to the lab, how does the lab determine it is an adequate sample?
9. Name four other diagnostics that can be done on this patient to further understand his condition.
10. If obtaining blood cultures, how many sets are typically obtained?
11. When choosing an antibiotic to treat this patient, it is important to try to cover for all
12. pathogens, especially gram-negative organisms. True or false?
13. When treating on an outpatient basis, what class of drug should be used for this previously healthy man with no use of antimicrobial therapy within the previous 3 months?
14. Although there have been cases of resistance against this class, it is still recommended for pts without risk. Please write out the Rx directions the way with the med and the sig how you would write it for the pt.
15. The choice of antibiotic therapy depends on three important factors. What are they?
16. In most cases, improvement is seen within __________ to _________ hours of initiation of antibiotics.
17. Should cough medicine be recommended?
18. Name two patient education points you would
Collepals.com Plagiarism Free Papers
Are you looking for custom essay writing service or even dissertation writing services? Just request for our write my paper service, and we'll match you with the best essay writer in your subject! With an exceptional team of professional academic experts in a wide range of subjects, we can guarantee you an unrivaled quality of custom-written papers.
Why Hire Collepals.com writers to do your paper?
Quality- We are experienced and have access to ample research materials.
We write plagiarism Free Content
Confidential- We never share or sell your personal information to third parties.
Support-Chat with us today! We are always waiting to answer all your questions.