Case Study Back pain: A 42-year-old male reports pain in his lower back for the past month. The pain sometimes radiates to his left leg. In determining the cause of the back pain, based on your knowledge of anatomy, what nerve roots might be involved? How would you test for each of them? What other …
Navigating Headache Challenges: A Comprehensive Analysis through Episodic/Focused SOAP Note CASE STUDY: A 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. ASSIGNMENT: -Use the Episodic/Focused SOAP Template and create an episodic/focused …
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Episodic/Focused SOAP Note Template Patient Information: Initials, Age, Sex, Race Subjective: CC (chief complaint) a BRIEF statement identifying why the patient is here – in the patient’s own words – for instance “headache”, NOT “bad headache for 3 days”. HPI (history of present illness): This is the symptom analysis section of your note. Thorough …
Focused SOAP Note Template Patient Information: Initials, Age, Sex, Race S. CC (chief complaint): A brief statement identifying why the patient is here, stated in the patient’s own words (for instance “headache,” not “bad headache for 3 days”). HPI: This is the symptom analysis section of your note. Thorough documentation in this section is …
Weight Management Strategies for Sedentary Professionals: A Case Study Approach Certain patient groups may have specific concerns related to their unique demographics. Conditions pertaining to men’s or women’s health, older adults, college students, LGBTQ individuals, athletes, those with distinct cultural beliefs, or individuals undergoing palliative or end-of-life care all fall within this category. It’s …
Tension-Type Headache in a 20-Year-Old Male: Comprehensive Patient Assessment and Diagnosis CASE STUDY: A 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. ASSIGNMENT: -Use the Episodic/Focused SOAP Template and create an episodic/focused …
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SOAP Note Analysis Instructions Using evidence-based resources, answer the following questions and support your answers using current evidence from the literature: Analyze the Subjective Portion of the Note: List additional information that should be included in the documentation. Analyze the Objective Portion of the Note: List additional information that should be included in the documentation. …
Title: Documentation of Problem-Based Assessment of the Head, Ears, and Eyes. Purpose of Assignment: To learn the required components of documenting a problem-based subjective and objective assessment of the head, ears, and eyes and to identify abnormal findings. Course Competency: Demonstrate physical examination skills of the head, ears, and eyes, nose, mouth, neck, and regional …
THE HISTORY AND PHYSICAL (H & P) Format I.Chief Complaint Why the patient came to the hospital Should be written in the patient’s own words II.History of Present Illness (HPI) a chronologic account of the major problem for which the patient is seeking medical care according to Bates’ A Guide to …
Benign prostatic hyperplasia SOAP note Instructions This is a SOAP note Primary diagnosis: benign prostatic hyperplasia Differential diagnosis: UTI, urethral stricture, bladder calculi references no older than 2 years. Abnormal findings are placed in a bold and red tint. no cover page Solution THE HISTORY AND PHYSICAL (H&P) Chief Complaint “I have been …
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