Make a SOAP Note: Assessing the Heart, Lungs, and Peripheral Vascular System
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Temperature: 97.9 oral
Respiratory rate: 32, labored
Heart rate: 112, tachycardic
BP right arm: 148/88
Oxygen saturation: 90% on room air
Weight: 210 lbs, stable
Skin: Cool, diaphoretic
Thorax and lungs: Thorax symmetrical; diminished breath sounds right middle and lower lobes; no rales, rhonchi, or wheezes; breath sounds vesicular with no adventitious sounds left lung
Cardiovascular: Heart rate is irregular with good S1, S2; no S3 or S4; no murmur
Abdomen: Protuberant with normoactive bowel sounds auscultated x4 quadrants
Peripheral vascular: Right calf with 2+ edema, erythema; warmth and tenderness on palpation noted; left lower extremity without edema or erythema; 2+ dorsalis pedis pulses bilaterally
Instructions: Your Discussion post should be in the SOAP Note format, rather than the traditional narrative style Discussion posting format. Refer to the Comprehensive SOAP Template/Exemplar on the attachments below.
Address all these in the SOAP Note:
1. A description of the health history you would need to collect from the patient in the case study 2.
2. Explain what physical exams and diagnostic tests would be appropriate and how the results would be used to make a diagnosis.
3. List five different possible conditions for the patient’s differential diagnosis, and justify why you selected each.
REMINDER: Please make a SOAP NOTE for this case. Make your own patient’s data, applicable health history, review of systems, P.E., labs, etc. Incorporate the data from the case 2 in the SOAP note that you will do… This is not essay ok…. I need SOAP note (Nurse Practitioner/RN/MD makes SOAP note)… Be guided with the templates/exemplar… Don’t copy paste. Formulate your own… Don’t forget to cite the Five different possible conditions (Differential diagnosis) and have Reference lists too.
· Ball, J. W., Dains, J. E., Flynn, J. A., Solomon, B. S., & Stewart, R. W. (2015). Seidel’s guide to physical examination (8th ed.). St. Louis, MO: Elsevier Mosby.
o Chapter 13, “Chest and Lungs” (pp. 260-293)
This chapter explains the physical exam process for the chest and lungs. The authors also include descriptions of common abnormalities in the chest and lungs.
o Chapter 14, “Heart” (pp. 294-331)
The authors of this chapter explain the structure and function of the heart. The text also describes the steps used to conduct an exam of the heart.
o Chapter 15, “Blood Vessels” (pp. 332-349)
This chapter describes how to properly conduct a physical examination of the blood vessels. The chapter also supplies descriptions of common heart disorders.
· Dains, J. E., Baumann, L. C., & Scheibel, P. (2016). Advanced health assessment and clinical diagnosis in primary care (5th ed.). St. Louis, MO: Elsevier Mosby.
o Chapter 8, “Chest Pain” (pp. 81–96)
This chapter focuses on diagnosing the cause of chest pain and highlights the importance of first determining whether the patient is in a life-threatening condition. It includes questions that can help pinpoint the type and severity of pain and then describes how to perform a physical examination. Finally, the authors outline potential laboratory and diagnostic studies.
o Chapter 11, “Cough” (pp. 118-147)
A cough is a very common symptom in patients and usually indicates a minor health problem. This chapter focuses on how to determine the cause of the cough through asking questions and performing a physical exam.
o Chapter 14, “Dyspnea” (pp. 159–173)
The focus of this chapter is dyspnea, or shortness of breath. The chapter includes strategies for determining the cause of the problem through evaluation of the patient’s history, through physical examination, and through additional laboratory and diagnostic tests.
o Chapter 26, “Palpitations” (pp. 310-317)
This chapter describes the different causes of heart palpitations and details how the specific cause in a patient can be determined.
o Chapter 33, “Syncope” (pp. 390-397)
This chapter focuses on syncope, or loss of consciousness. The authors describe the difficulty of ascertaining the cause, because the patient is usually seen after the loss of consciousness has happened. The chapter includes information on potential causes and the symptoms of each.
· Sullivan , D. D. (2012). Guide to clinical documentation (2nd ed.). Philadelphia, PA: F. A. Davis.
o Chapter 6, “Outpatient Charting and Communications” (pp. 119–141)