Writer Choice

42605 Please write a SOAP note on a 36year old male with complaints of headache. Also please use “Bates Guide to Health Assessment” textbook as one of your sources that is to be cited in text.

Hello, please the due date for this SOAP comprehensive write up is Monday July 8th at 6pm

(See Bates’ page 30-36 for example SOAP and supplementary Comprehensive SOAP example located in course)

Step 2: Written Comprehensive SOAP Component: 185 Points *For this step, you will submit a written comprehensive SOAP to both course Assignment AND Forum. *Prepare for the assignment by reviewing the course content and resources (readings, videos, SOAP examples, websites, etc.). Students should demonstrate graduate level ability with applying principles to complete this assignment as they prepare for an advanced practice role. *The comprehensive health assessment SOAP is constructed by performing an interview (Step 1: subjective) and a head-to-toe physical examination (objective) of each system as indicated on the rubric while identifying symptoms (subjective) and signs (objective) to generate differential diagnoses. Utilize evidence-based resources and guidelines to determine working diagnosis (assessment) and plan of care (plan). Cite resources in-text and include a reference page in APA format. *Compose your comprehensive SOAP in Word using an outline or bullet format (your written document should contain all elements of the SOAP, including the subjective data gathered during Step 1 interview). No Title Page is needed. Convert the comprehensive SOAP document to PDF format (name your file according to the file naming standard in the syllabus). Then submit your comprehensive SOAP as an attachment to course Assignment for grading by faculty AND to the Forum for peer review. *Once you submit the comprehensive SOAP to the forum, you will have access to view classmates comprehensive SOAP to complete peer review component.
Comprehensive Health Assessment SOAP Grading Rubric

Student: Faculty:
SUBJECTIVE DATA POINTS EARNED PATINT INFORMATION (Bates’ p. 8-9) • 1 Point Age • 1 Point Gender • 1 Point Ethnicity • 1 Point Health Insurance (yes/no) • 1 Point Information Source/Reliability CHIEF COMPLAINT (Bates’ p. 9) • 2 Points CC in “patient’s own words” (use quotes) HISTORY OF PRESENT ILLNESS (Bates’ p. 9) Chronological order of symptoms (must include all pertinent attributes) • 1 Point Location (Where is it? Does it radiate?) • 1 Point Quality (What is it like?) • 1 Point Quantity/Severity (How bad is it?) • 1 Point Timing (Onset? When does it start? How long does it last? How often does it occur?)
• 1 Point
Setting/Context at Onset (Are there any associated environmental, personal, emotional, or other circumstances that may have contributed to the illness?)
• 1 Point Aggravating or Relieving Factors (Is there anything that makes it better or worse?) • 1 Point Associated Manifestations (Are there any associated signs or symptoms that accompany it?) • 1 Point Self-Treatment • 1 Point Past Medical, Family, or Social History related to CC/HPI (only include history related to CC/HPI here) PAST MEDICAL HISTORY (Bates’ p. 10) • 2 Points Childhood Illnesses (chicken pox, measles, mumps, rubella, etc.) • 2 Points Adult Illnesses • 2 Points Health Maintenance → Immunizations (population appropriate: influenza, pneumonia, zostavax, Tdap, etc.); include year • 2 Points Health Maintenance → Screening tests (population appropriate: cholesterol, eye/hearing exams, cancer screening, etc.); include year • 2 Points Past Hospitalizations/Surgeries • 2 Points Injuries/Accidents • 2 Points Current Medications with route, dosage, and frequency • 2 Points Allergies (food, drugs, environment, insects, latex – address all)
3

FAMILY HISTORY (Bates’ p. 10-11, 32)
• 2 Points
Grandparents, Parents, Siblings, Children, Significant Other (include a narrative discussing family members’ health and genetic conditions, age, relationship to patient, and cause of death for deceased family members).

• 4 Points
Pedigree (genogram) – must be created from computer (no handwritten genogram). Include a key identifying what each symbol represents. Helpful resources: Smartdraw, Progeny, Edraw, and Genopro
PERSONAL AND SOCIAL HISTORY (Bates’ p. 11) • 2 Points Family Structure • 2 Points Educational Level • 2 Points Occupational History • 2 Points Economic Status • 2 Points Home Conditions/Environment • 2 Points Spiritual and Cultural Information • 2 Points Tobacco/Electronic Cigarettes • 2 Points Recreational Drugs • 2 Points Alcohol • 2 Points Caffeine • 2 Points Sleep • 2 Points Safety Measures (seatbelt, smoke detectors, sunblock, etc.) • 2 Points Diet (24-hour diet recall) • 2 Points Exercise REVIEW OF SYSTEMS (Bates’ p. 11-13) • 3 Points General • 3 Points Skin/Hair/Nails • 3 Points Head/Face • 3 Points Eyes • 3 Points Ears • 3 Points Nose/Sinuses • 3 Points Mouth/Throat • 3 Points Neck • 3 Points Breasts • 3 Points Respiratory • 3 Points Cardiovascular/Peripheral Vascular (CV/PV) • 3 Points Gastrointestinal • 3 Points Urinary
4

• 3 Points
Genital FEMALE: • Menarche: age • Menopause: age, sequelae • Menses: LMP, # days in cycle, # days of menstrual flow, dysmenorrhea, metrorrhagia, menorrhagia • Vaginal discharge, pruritus, etc. • Pregnancies: gravida, premature births, term births, abortions, living children, pregnancy, complications • Contraceptive use: condoms, pill, IUD, diaphragm, etc. • STD contact and prevention • HIV exposure/concern MALE: • Penile: discharge, lesions, erectile dysfunction • Scrotum: lumps, testicular issues, self-exam • STD contact and prevention • HIV exposure/concern • Hernias
• 3 Points Musculoskeletal • 3 Points Psychiatric • 3 Points Neurologic • 3 Points Hematologic • 3 Points Endocrine OBJECTIVE DATA PHYSICAL EXAM (Bates’ p. 14-24) • 3 Points General • 3 Points Height/Weight/BMI/Vital Signs • 3 Points Skin • 3 Points Head/Face • 3 Points Eyes (defer only the ophthalomoscopic exam) • 3 Points Ears (perform otoscopic exam) • 3 Points Nose/Sinuses • 3 Points Mouth/Throat • 3 Points Neck • 3 Points Lymphatic • 0 Points Breasts (defer) • 3 Points Thorax/Lungs • 3 Points Cardiovascular/Peripheral Vascular (CV/PV) • 3 Points Abdomen • 3 Points Musculoskeletal • 3 Points Neurologic • 0 Points Genitalia/Rectum (defer)
5

DIFFERENTIAL DIAGNOSES (Bates’ p. 27-28, 46) • 3 Points • List differential diagnoses (possible causes of health problem) based on findings (minimum of 3 and maximum of 8). ASSESSMENT Utilize evidence-based resources such as The Biomedical Library database list, Up-To-Date decision support system, Current Medical Diagnosis & Treatment 2019, and the Bates’ textbook for developing one or more working diagnoses and plan of care. Using APA guidelines, include in-text citation of evidence-based resources supporting assessment and plan, and include reference page. WORKING DIAGNOSIS (Bates’ p. 27-28)
• 4 Points
• Establish one or more working diagnoses (high certainty of actual cause of health problem). • Include rationale for ruling in working diagnoses based on explicit findings/evidence. • Include rationale for ruling out differential diagnoses based on lack of explicit findings/evidence. • Cite evidence-based resources in-text.
PLAN PLAN OF CARE (Bates’ p. 29)
• 8 Points
• Develop a comprehensive plan of care for each working diagnosis based on best practices. • Include all appropriate interventions and rationale for each intervention. • Use evidence-based resources to support the plan of care. • Cite evidence-based resources in-text. • Include reference page with list of evidence-based resources used to support assessment and plan. • Consider medication, tests/diagnostics, therapy, consultations/referrals, health promotion/disease prevention, cultural considerations, mutual plan, follow-up. • Patient/family education – must include pertinent teaching for each applicable diagnosis.
PROBLEM LIST (Bates’ p. 37)
• 2 Points
• List all the patient’s problems based on subjective and objective findings. • No plan is needed for the problem list.
• 15 Points • Peer Review feedback: Forum cross post Deductions: • Points will be deducted for late submission (Penalty for late work: 5% deduction for up to 6 hours late; thereafter, the deduction will be 10% per day (deducted from the graded score). • Points will be deducted for grammatical errors and incorrect APA in-text citation and reference page (up to 10%)
TOTAL POSSIBLE POINTS = 200

Example of SOAP note is below: Please follow this. Thank you
University of South Alabama College of Nursing NU 518 Comprehensive Soap Example and Format (See Bates’ page 30-36 for example SOAP note)
Patient Information: age/gender/ethnicity/health insurance (p.8-9). Source and Reliability of Information: person providing information; is this person a reliable source of information? (p.8-9). S – Subjective Data CC: (chief complaint) include a BRIEF statement identifying why the patient is seeking care (quote patient’s own words), example for 25 y/o male: “I have been experiencing indigestion after eating” (p.9). HPI: (history of present illness) provide a complete, clear, and chronologic account of the problem(s) prompting the patient to seek care. List each attribute and describe the symptom based on patient’s response (p.9). Attributes with example using the CC indigestion: • Location (Where is it? Does it radiate?) – upper stomach, chest, and throat; radiates across chest • Quality (What is it like?) – burning sensation • Quantity/Severity (How bad is it?) – discomfort from burning sensation rates 6 on scale of 1 to 10 • Timing (When did/does it start? How long does it last? How often does it occur?) – sudden onset 5 days ago after eating Mexican food; for the past 5 days, occurs every day after eating lunch and dinner, and can last 3 hours or longer • Setting or context at onset (Are there any associated environmental, personal, emotional, or other circumstances that may have contributed to the illness?) – patient believes eating spicy Mexican food irritated his stomach and triggered heartburn • Aggravating or relieving factors (Is there anything that makes it better or worse?) – spicy greasy foods seem to make symptoms worse (“For the past 5 days, me and friends have been eating a lot of Mexican food, pizza, and fried chicken”); cutting back on the amount of food on day 5 helped decrease the severity of heartburn, and taking Tums helps relieve some of the burning • Associated manifestations (Are there any associated signs or symptoms that accompany it?) – heartburn, burping, and coughing • Self-treatment – OTC Tums 750mg, 2 tabs after lunch and dinner with some relief after about 3 hours • Past Medical, Family, or Social History related to CC/HPI (only include history related to CC/HPI here) – patient with history of H. pylori gastritis, consumes fast foods daily, quit smoking 2 years ago; mother with history of reflux; father with history of gastric ulcer

PMHx: (past medical history) (p.10). • Childhood illnesses • Major adult illnesses; include date of onset Example using the CC indigestion: IBS – onset 15 years ago, non-compliant with medication; H. pylori gastritis – treated 10 years ago • Health maintenance: immunizations (population appropriate: influenza, pneumonia, zostavax, Tdap, etc.); include year • Health maintenance: screening tests (population appropriate: cholesterol, eye/hearing exams, cancer screening, etc.); include year • Past hospitalizations/surgeries • Injuries/accidents • Current medications with dosage and frequency; include OTC medications; is patient compliant with medications? Example using the CC indigestion: Levsin 0.125mg po before meals, skips doses; Tums 750mg po 2 tabs after lunch and dinner for last 5 days as needed for heartburn • Allergies: food, drugs, environmental, insects, and latex (address all and discuss specific reactions if applicable) FamHx: (family history) include a narrative discussing family members’ health and genetic conditions, age, relationship to patient, and cause of death for deceased family members (p.10-11, 32). The narrative provides the foundation for developing the genogram (include grandparents, parents, siblings, children, significant other). Develop a computer-generated genogram illustrating family history; include a key identifying what each symbol represents (p. 31). Resources: https://www.smartdraw.com/genogram/ http://www.progenygenetics.com/ https://www.edrawsoft.com/genogram/ https://www.genopro.com/ Personal/SocHx: (personal and social history) (p.11). • Family structure: birthplace, marital status, family relationships, support system, etc. • Education level • Occupational history/hobbies • Economic status • Home conditions/environment: exposure to toxins/allergens in home, school, or work, etc. • Spiritual and cultural background • Tobacco use/electronic cigarettes • Recreational drugs • Alcohol • Caffeine
• Sleep pattern • Safety measures: seat belt/home smoke detector/sunblock • Diet: typical diet/24-hour diet recall Example using the CC indigestion: breakfast – plain toast and cereal lunch – beef enchilada, 2 tacos, tortilla chips, sweet tea dinner – fried chicken, French fries, Pepsi • Exercise ROS: (review of systems) include data identifying the presence or absence of symptoms related to each system. This is information the patient gives you about each body system that may help reveal additional symptoms that were overlooked or unrelated to the present illness. Record all pertinent positives and negatives for each system. List each system in order from head to toe using an outline or bullet format: (p.11-13). General Skin/hair/nails Head/face Eyes etc. Example using the CC indigestion: Gastrointestinal – reports indigestion and heartburn for last 5 days after eating spicy greasy foods for lunch and dinner each day; reports burning sensation that rates 6 on pain scale is partially relieved with Tums; reports burping/cough with indigestion; currently treated for IBS; past history of gastritis; denies nausea/vomiting/diarrhea; denies blood in stool; regular daily brown BM for last 5 days; appetite good; denies gallbladder or liver problems; no history of colonoscopy or EGD; no family history of gastrointestinal cancer. O – Objective Data PE: (physical exam) include data gathered through physical examination of each body system. Document from head to toe using an outline or bullet format: (p.14-24). General Height/ Weight/BMI/Vital Signs Skin Head/Face Eyes etc. Example using the CC indigestion: Abdomen – bowel sounds present in all 4 quadrants; nondistended; no tenderness with palpation; no rebound tenderness; soft; no palpable masses; liver span 8 cm; spleen and kidneys nonpalpable; no lesions or scars; no CVA tenderness.

Differential Diagnoses: List possible causes of health problem based on findings (p.27-28, 46). Minimum of 3 and maximum of 8. Example using the CC indigestion: 1. Esophageal reflux disease (GERD) 2. Hiatal hernia 3. Gastritis 4. Peptic ulcer disease 5. Gastric cancer 6. Food allergy A – Assessment Utilize evidence-based resources such as The Biomedical Library database list, Up-To-Date decision support system, Current Medical Diagnosis & Treatment 2019, and the Bates’ textbook for developing one or more working diagnoses and plan of care. Using APA guidelines, include in-text citation of evidence-based resources supporting assessment and plan, and include reference page. • Working Diagnosis: Establish one or more working diagnoses based on high certainty of actual cause of health problem (p.27-28). Include rationale for ruling in working diagnoses. Include rationale for ruling out differential diagnoses based on lack of explicit findings/evidence. Cite evidence-based resources in-text. Example using the CC indigestion: 1. GERD – heartburn, indigestion, and cough are highly indicative of GERD and are reasons to rule in GERD as the cause of patient’s health problem (McQuaid, 2019). These classic symptoms are typically triggered by overproduction of stomach acid. Patient has been consuming foods that are spicy/greasy which tend to increase gastric acid production (McQuaid, 2019). 2. Hiatal hernia – acid moving up into esophagus is reason to possibly rule in hiatal hernia since this is a common cause of acid reflux and heartburn (McQuaid, 2019). 3. Gastritis – patient is not experiencing nausea and hematemesis which are symptoms of erosive gastritis, and therefore, a reason to rule out this diagnosis (McQuaid, 2019); consider nonerosive gastritis if no improvement since patient has history of H. pylori gastritis (McQuaid, 2019). 4. Peptic ulcer disease – patient is not experiencing epigastric pain which is the hallmark symptom of peptic ulcer disease, and therefore, a reason to rule out this diagnosis (McQuaid, 2019). 5. etc. P – Plan • Develop a comprehensive plan of care for each working diagnosis based on best practices. • Include all appropriate interventions and rationale for each intervention. • Use evidence-based resources to support the plan of care.
• Cite evidence-based resources in-text. • Include reference page with list of evidence-based resources used to support assessment and plan. • Consider in plan of care: medication, tests/diagnostics, therapy, consultations/referrals, health promotion/disease prevention, cultural considerations, patient agreement/participation with plan, follow-up (p. 29). • Patient/family education – must include pertinent teaching for each applicable diagnosis. Example using the working diagnosis GERD: • Encourage lifestyle modifications such as eating smaller meals and eliminating acidic/spicy foods. Foods that are spicy/greasy precipitate reflux by increasing gastric acid content (Fiorentino, 2019; McQuaid, 2019; Smith, 2018); encourage a healthy diet (brochure provided). • OTC Tums 1000mg 2 tabs every 4 hours PRN for recurring heartburn to neutralize the gastric acid; for no relief in 24 hours, start OTC Zantac 150mg BID to decrease gastric acid production (McQuaid, 2019; Smith, 2018). • Follow up in 4 weeks to re-evaluate. For worsening or unresolved symptoms with GERD, will refer to gastroenterologist for possible EGD and/or esophagram to determine other possible causes; start PPI (Omeprazole 20mg QD); side effects of Omeprazole such as diarrhea and vitamin B deficiency discussed with patient; ultrasound (or other radiographic study) to rule in or rule out hiatal hernia (Levine & Carucci, 2018; McQuaid, 2019; Smith, 2018). • etc. Problem List: Generate a list that summarizes the patient’s problems based on subjective and objective findings (p.37). No plan is needed for the problem list. Example using the CC indigestion: Heartburn Belching Coughing Indigestion Unhealthy diet History of gastritis IRS

References

Fiorentino, E. (2019). The consumption of snacks and soft drinks between meals may contribute to the development and to persistence of gastro-esophageal reflux disease. Medical Hypotheses, 125, 84-88. doi: https://doi.org/10.1016/j.mehy.2019.02.034 Levine, M. S., & Carucci, L. R. (2018). Esophageal abnormalities in gastroesophageal reflux disease. Abdominal Radiology, 43(6), 1284–1293. doi: https://doi.org/10.1007/s00261-0171412-0 McQuaid, K. R. (2019). Gastrointestinal disorders. In M. Papadakis & S. McPhee (Eds.), Current medical diagnosis and treatment (pp. 618-623). Retrieved from https://accessmedicinemhmedical-com.libproxy.usouthal.edu/book.aspx?bookid=2449 Smith, H. (2018). Heartburn, gastro-oesophageal reflux disease and non-erosive reflux disease. Professional Nursing Today, 22(4), 25–30.

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