What details did the patient provide regarding her personal and medical history?
What details did the patient provide regarding her personal and
medical history? Select a patient whom you examined during the last
three weeks. With this patient in mind, address the
following in a SOAP Note:
?Subjective: What details did the patient provide regarding
her personal and medical history?
?Objective: What observations did you make during the
physical assessment?
?Assessment: What were your differential diagnoses? Provide a
minimum of three possible diagnoses. List
them from highest priority to lowest priority. What was your
primary diagnosis and why?
?Plan: What was your plan for diagnostics and primary
diagnos??????is? What was your plan for
treatment and management, including alternative therapies?
Include pharmacologic and
nonpharmacologic treatments, alternative therapies, and
follow?up parameters, as well as a rationale for
this treatment and management plan.
?Reflection notes: What would you do differently in a similar
patient evaluation?
pt is a 35 year old black female who weighs 250lbs trying to
get pregregnate and she also diganosed with
primary hypertention was placed of procadia 10mg q day .She
has never tried to have a baby because she
was so busy building her Law firm .
DO THE SOAP NOTE JUST LIKE THE EXAMPLE PAPER AND MAKE UP
STUFF TO FILL IT IN
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