Assignment: Practicum Experience- Episodic SOAP Note Part 1

A Sample Answer For the Assignment: Assignment: Practicum Experience- Episodic SOAP Note Part 1

Title: Assignment: Practicum Experience- Episodic SOAP Note Part 1

SUBJECTIVE DATA:

Chief complain (CC) persistent cough

History of Present Illness (HPI)

TM is an African American boy aged 11 who complain of a dry cough that has lasted more than two weeks. The dry cough occurred slowly and has been persistent. TM reports that the cough started with pharyngitis that lasted two days, which was followed by chest congestion and a dry cough. He says he does not have chest pain or fever when he coughs unlike reports by his parents, but he reports related symptoms of malaise, occasional headaches, and dyspnea. The discrepancies may have resulted from the fact that his persistent cough has been developing over time. Owing to these symptoms, TM stopped playing soccer at school. Currently, he has not used any medicine. According to TM even though his throat is no longer painful, or noting vomiting or having any signs of nausea, and his rating for severity of symptom discomfort is 2/10, he still do not have appetite to eat any kind of food.

Medications:

Robitussin: 5ml every twelve hours to treat cough

Two puffs of Albuterol 90mcg taken after a period of 4 to 6 hours

Allergies: No known allergies.

PMH: TM has a history of asthma, which was first diagnosed in 2014. He has not had any

hospitalization because of this condition.

Preceptor’s Initials_____

PSH: TM has not had any surgeries, apart from penis circumcision at 2 months old.

Sexual/Reproductive History: not pertinent; patient is not sexually active.

Personal or Social History: TM lives with one younger sister and his parents. Currently, he is in sixth grade. According to him, he performs well in school and likes to go to school. His mother is a store manager while his father is a firefighter. TM does not smoke or uses drugs at home or drink alcohol currently, and has no past history of such behavior either. He eats food regularly and sleeps well apart from when he is congested.

Immunization History: TM’s vaccines are up to date.

Review of Systems: TM is diagnosed with shortness of breath, headache, loss of appetite, cough, malaise, and chest congestion. Currently he is using albuterol inhaler for asthma, has no chills, fever, sore throat, palpitations, syncope, nausea and vomiting, and no signs of weight loss.

OBJECTIVE DATA:

Physical Exam: Vitals: Oral Temperature 98.6°F, pulse 88, BP 100/60, Respiratory Rate 18, room air saturation 99%, BMI 17.0, Height 54 inches, Weight 70.5 lbs.

General: No acute distress noted on assessment, he is well-nourished and very friendly.

HEENT Examination: Head is normocephalic. Patient has evenly distributed dark and thick hair.

PERRLA: Pink conjunctiva and white sclera. His ears are clean and canals are bilateral. Throat

shows no redness and the pharynx is intact. The patient shows no signs of sinus drainage or a loose tooth. The neck is supple with no masses or palpable lymph node. The lungs have no

consolidation and test positive for fine rales. There is no stridor or wheezing, no pleuritic chest Assignment Practicum Experience- Episodic SOAP Note Part 1

Preceptor’s Initials_____

symptoms noted no use of accessory muscles, and no tachypnea. The patient presents fine rales without consolidation.

Peripheral Vascular/Cardiovascular Assessment: Respiration, Rate, and Rhythm – no gallops or murmurs and no edema noted. The patient have palpable peripheral pulses.

Gastrointestinal: The abdomen is nontender, nondistended, and soft. The patient has positive bowel sounds in all the four quadrants and does not have any hepatosplenomegaly.

Musculoskeletal: Patient exhibits full range of motion with consideration of all extremities.

Skin: Warm to touch and no rashes noted.

Diagnostic test results: Normal WBC Count.

ASSESSMENT

Differential Diagnosis

Mycoplasma pneumonia: This is the commonest cause of infection in the lower respiratory tract among children aged at least five years and adults (Burns et al., 2017). The onset of this symptom is slow and is characterized by a dry cough, malaise, fever, or head ache. The child might not appear ill, but after performing lung auscultation, rhonchi and rales are often present. In most cases, CBC is normal as explained by Dains and others (2016). TM exhibits these symptoms.

Bronchiolitis: This typically occurs in infants aged not more than 2 years. It is associated

with runny nose, coughing, and pyrexia, and is usually followed by wheezy breathing and tachypnea. According to Dains and others (2016), as inflammation increases, the child experiences more coughs.

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Bacterial pneumonia: According to Dains et al. (2016), bacterial pneumonia is normally attributed to pleuritic pain in the chest,

dyspnea, coughing with greenish or rust-brown phlegm, chills and febricity, as well as inspiratory crackles heard through auscultation.

PLAN

Discontinued Medications:

The patient will not be required to take Robitussin 5ml after 12-hour periods. According to Buttaro and others (2017), this drug, which is used to suppress the cough, is not appropriate because cough reflex and phlegm expectoration help in getting rid of heavy secretions.

New Medications started:

TM will be put on Azithromycin 250mg tabs everyday daily for five days. According to Buttaro and others (2017), the extended half-life of azithromycin makes it possible to have a shorter duration of therapy, which usually takes five days. Acetaminophen Suspension (160mg/5ml) will be taken every 6 hours for the treatment of headaches. The physician should not administer the medicine more than five times daily.

Alternative therapies

One of the alternative therapies is letting the patient to rest, which is critical in the treatment of malaise. Similarly, it is imperative to administer fluid hydration. This will help in the expectoration of phlegm, as well as maintenance of mucous secretions and keeping membranes moist. Using a cold mist vaporizer to increase humidification, this increases moisture

particularly in dry climate as recommended by Burns et al. (2017).

Health Promotion strategies

Practitioners ought to educate patients and their family on the need to avoid smoke and contact

Preceptor’s Initials_____

with individuals with respiratory infections particularly in school or at home. This is because avoidance reduces the risk of pneumonia as Buttaro et al. (2017) explain. According to Buttaro et al. (2017), it is imperative to counsel patients on all visits regarding injury prevention and safety such as campus and automobile safety, as well as mental health problems such as eating disorders, substance misuse, and stress. It is also important to encourage patients to engage in daily exercise, eat healthy foods rich in nutrients, fiber, and vitamins (Buttaro et al., 2017).

Disease Prevention strategies

FNP in any settings should educate parents and guardians on the importance of screening patients and educating them on the benefits of immunization and its risk factors. Patients who are more vulnerable to pneumonia should get the pneumonia vaccine. Similarly, they ought to get the flu shot according to Buttaro et al. (2017). TM has received all the recommended vaccines. There is need to educate him and his parents/guidance on the possible side effects of all vaccines as recommended by Buttaro and others (2017). It is imperative to ensure that patients keep a record of their vaccination history. To help improve vaccination rate, healthcare staff should be involved using the team approach. To ensure adherence to future annual visits, 11-year-old adolescents should stick to the recommended routine. Scenery it is essential to evaluate the physical state of adolescence engaged in sports, and this should include orthopedic screening.

Diagnostic tests ordered

After antibiotic therapy in two weeks Chest x-ray and CBC will be taken.

Preceptor’s Initials_____

Consultation or Referrals

If pneumonia persists for more than a month or recurs, it will be necessary to take TM through further pulmonary evaluation. According to Burns et al. (2017), if this evaluation does not help, TM should be referred to inpatient admission or a specialist. TM will also require an in-office follow-up after three weeks to reexamine x-ray and lab results, as well as any other concerns.

Education

As recommended by Arcangelo (2013), the patient should take azithromycin with food to prevent stomach upset. Burns et al. (2017) explain that symptoms can last for up to 6 to 8 weeks.

REFLECTION NOTES

Through this exercise, I have learned that M. pneumonia is suspected in case of the presence of cold agglutinins in the peripheral blood sample. Furthermore, I have learned that M. pneumonia is confirmed by mycoplasma PCR or IgM testing as Burns et al. (2017) explain. As Dains et al. (2016) explicate a titer of at least 1:32 supports pneumonia diagnosis. Before this exercise, I have no idea that it is critical to take a chest x-ray with M. pneumonia diagnosis. Buttaro and others (2017) report that chest x-ray is necessary for people who have been diagnosed with pneumonia. The x-ray helps both in establishing the diagnosis and ruling out complications. Nevertheless, the diagnosis of pneumonia cannot be excluded simply because of a negative chest x-ray film. Another significant lesson I learned is that M. pneumoniae is one of the atypical, nonbacterial causative agent of pneumonia. Buttaro et al. (2017) explains that it is hard to use the common methods to stain and visualize these organisms because they have no cell walls. In case I am presented with a different patient with similar symptoms, I would test for whooping cough and evaluate the role of allergies and sinusitis.

In addition to Journal Entries, SOAP Note submissions are a way to reflect on your Practicum Experiences and connect these experiences to your classroom experience. SOAP Notes, such as the ones required in this course, are often used in clinical settings to document patient care. Please refer to the Seidel, et. al. book excerpt and the Gagan article located in this week’s Learning Resources for guidance on writing SOAP Notes.

You must submit your SOAP Notes using SAFE ASSIGN.

To Prepare:

Review the Episodic SOAP Note Exemplar provided in this week’s Resources in preparation for this Assignment.
Use the Episodic SOAP Note Template to complete this Assignment.
After completing this week’s Practicum Experience, select a patient that you examined during the last 3 weeks. With this patient in mind, address the following in a SOAP Note:

Subjective: What details did the patient provide regarding his or 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 diagnosis? What was your plan for treatment and management including alternative therapies?
Reflection notes: What would you do differently in a similar patient evaluation?
Please Note: Your Episodic SOAP Note Assignment .

To Prepare:

Lopes Write Policy

For assignments that need to be submitted to Lopes Write, please be sure you have received your report and Similarity Index (SI) percentage BEFORE you do a “final submit” to me.

Once you have received your report, please review it. This report will show you grammatical, punctuation, and spelling errors that can easily be fixed. Take the extra few minutes to review instead of getting counted off for these mistakes.

Review your similarities. Did you forget to cite something? Did you not paraphrase well enough? Is your paper made up of someone else’s thoughts more than your own?

Visit the Writing Center in the Student Success Center, under the Resources tab in LoudCloud for tips on improving your paper and SI score.

Late Policy

The university’s policy on late assignments is 10% penalty PER DAY LATE. This also applies to late DQ replies.

Please communicate with me if you anticipate having to submit an assignment late. I am happy to be flexible, with advance notice. We may be able to work out an extension based on extenuating circumstances.

If you do not communicate with me before submitting an assignment late, the GCU late policy will be in effect.

I do not accept assignments that are two or more weeks late unless we have worked out an extension.

As per policy, no assignments are accepted after the last day of class. Any assignment submitted after midnight on the last day of class will not be accepted for grading.

Communication

Communication is so very important. There are multiple ways to communicate with me:

Questions to Instructor Forum: This is a great place to ask course content or assignment questions. If you have a question, there is a good chance one of your peers does as well. This is a public forum for the class.

Individual Forum: This is a private forum to ask me questions or send me messages. This will be checked at least once every 24 hours.

Important information for writing discussion questions and participation

Welcome to class

Hello class and welcome to the class and I will be your instructor for this course. This is a -week course and requires a lot of time commitment, organization, and a high level of dedication. Please use the class syllabus to guide you through all the assignments required for the course. I have also attached the classroom policies to this announcement to know your expectations for this course. Please review this document carefully and ask me any questions if you do. You could email me at any time or send me a message via the “message” icon in halo if you need to contact me. I check my email regularly, so you should get a response within 24 hours. If you have not heard from me within 24 hours and need to contact me urgently, please send a follow up text to

I strongly encourage that you do not wait until the very last minute to complete your assignments. Your assignments in weeks 4 and 5 require early planning as you would need to present a teaching plan and interview a community health provider. I advise you look at the requirements for these assignments at the beginning of the course and plan accordingly. I have posted the YouTube link that explains all the class assignments in detail. It is required that you watch this 32-minute video as the assignments from week 3 through 5 require that you follow the instructions to the letter to succeed. Failure to complete these assignments according to instructions might lead to a zero. After watching the video, please schedule a one-on-one with me to discuss your topic for your project by the second week of class. Use this link to schedule a 15-minute session. Please, call me at the time of your appointment on my number. Please note that I will NOT call you.

Please, be advised I do NOT accept any assignments by email. If you are having technical issues with uploading an assignment, contact the technical department and inform me of the issue. If you have any issues that would prevent you from getting your assignments to me by the deadline, please inform me to request a possible extension. Note that working fulltime or overtime is no excuse for late assignments. There is a 5%-point deduction for every day your assignment is late. This only applies to approved extensions. Late assignments will not be accepted.

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Plagiarism is highly prohibited. Please ensure you are citing your sources correctly using APA 7th edition. All assignments including discussion posts should be formatted in APA with the appropriate spacing, font, margin, and indents. Any papers not well formatted would be returned back to you, hence, I advise you review APA formatting style. I have attached a sample paper in APA format and will also post sample discussion responses in subsequent announcements.

Your initial discussion post should be a minimum of 200 words and response posts should be a minimum of 150 words. Be advised that I grade based on quality and not necessarily the number of words you post. A minimum of TWO references should be used for your initial post. For your response post, you do not need references as personal experiences would count as response posts. If you however cite anything from the literature for your response post, it is required that you cite your reference. You should include a minimum of THREE references for papers in this course. Please note that references should be no more than 5 years old except recommended as a resource for the class. Furthermore, for each discussion board question, you need ONE initial substantive response and TWO substantive responses to either your classmates or your instructor for a total of THREE responses. There are TWO discussion questions each week, hence, you need a total minimum of SIX discussion posts for each week. I usually post a discussion question each week. You could also respond to these as it would count towards your required SIX discussion posts for the week.

I understand this is a lot of information to cover in 5 weeks, however, the Bible says in Philippians 4:13 that we can do all things through Christ that strengthens us. Even in times like this, we are encouraged by God’s word that we have that ability in us to succeed with His strength. I pray that each and every one of you receives strength for this course and life generally as we navigate through this pandemic that is shaking our world today. Relax and enjoy the course!

Hi Class,

Please read through the following information on writing a Discussion question response and participation posts.

Contact me if you have any questions.

Important information on Writing a Discussion Question

Your response needs to be a minimum of 150 words (not including your list of references)
There needs to be at least TWO references with ONE being a peer reviewed professional journal article.
Include in-text citations in your response
Do not include quotes—instead summarize and paraphrase the information
Follow APA-7th edition
Points will be deducted if the above is not followed

Participation –replies to your classmates or instructor

A minimum of 6 responses per week, on at least 3 days of the week.
Each response needs at least ONE reference with citations—best if it is a peer reviewed journal article
Each response needs to be at least 75 words in length (does not include your list of references)
Responses need to be substantive by bringing information to the discussion or further enhance the discussion. Responses of “I agree” or “great post” does not count for the word count.
Follow APA 7th edition
Points will be deducted if the above is not followed
Remember to use and follow APA-7th edition for all weekly assignments, discussion questions, and participation points.
Here are some helpful links
Student paper example
Citing Sources
The Writing Center is a great resource