History: Migraines and HTN

Order Instructions

This week, you will complete a comprehensive SOAP note.

Patient: RW

DOB: 12/5/1965

Allergy: NKDA

History: Migraines and HTN

Patient came to the clinic with a laceration on his left left caused by a chain saw accident. This happened 5 days ago and caregiver states patient refused to go to the Emergency room. Wound site is bright red and swollen. Some necrotic tissue.

Bactrim DS 800/160 twice a day for 10 days ordered

Doxycycline 100 mg twice a day for 10 days ordered

Wound care daily, wound cleanser, Santyl, 4×4 gauze and taped

Ibuprofen 800 mg q8hrs as needed

Review the Comprehensive SOAP Note Template.

Select a patient who you saw at your practicum site during the last 5 weeks. 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?

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.

Reflection notes: What was your “aha” moment? What would you do differently in a similar patient evaluation?