For this task, you’re to finish a medical case – narrated PowerPoint report that can observe the SOAP observe instance offered under. The case report will likely be primarily based on the medical case situation record under.
You might be to method this medical situation as if it’s a actual affected person within the medical setting.
Directions:
Step 1 – Learn the assigned medical situation and utilizing your medical reasoning expertise, determine on the diagnoses. This step informs your subsequent steps.
Step 2 – Doc the given info within the case situation below the suitable sections, headings, and subheadings of the SOAP observe.
Step three – Doc all of the traditional signs sometimes related to the diagnoses in Step 1. This info could NOT be given within the situation; you’re to acquire this info out of your textbooks. Embrace APA citations.
Instance of Steps 1 – three: You selected Angina after studying the medical case situation (Step 1) Overview of Signs (record of traditional signs): CV: sweating, squeezing, stress, heaviness, tightening, burning throughout the chest beginning behind the breastbone GI: indigestion, heartburn, nausea, cramping Ache: ache to the neck, jaw, arms, shoulders, throat, again, and enamel Resp: shortness of breath Musculo: weak spot
Step four – Doc the irregular bodily examination findings sometimes related to the acute and persistent diagnoses selected in Step 1. Once more, this info could NOT be given. Cull this info from the textbooks. Embrace APA citations.
Instance of Step four: You decided the affected person has Angina in Step 1 Bodily Examination (record of traditional examination findings): CV: RRR, murmur grade 1/four Resp: diminished breath sounds left decrease lobe
Step 5 – Doc the diagnoses within the applicable sections, together with the ICD-10 codes, from Step 1. Embrace three differential diagnoses. Outline every prognosis and help every differential prognosis with pertinent positives and negatives and what makes these decisions believable. This info could come out of your textbooks. Bear in mind to quote utilizing APA.
Step 6 – Develop a therapy plan for the diagnoses. Solely use Nationwide Medical Pointers to develop your therapy plans. This info won’t come out of your textbooks. Use your analysis expertise to find applicable tips. The therapy plan should handle the next: a) Medicines (embody the dosage in mg/kg, frequency, route, and the variety of days) b) Laboratory checks ordered (embody why ordered and what the outcomes of the check could point out) c) Diagnostic checks ordered (embody why ordered and what the outcomes of the check could point out) d) Vaccines administered this go to & vaccine administration types given, e) Non-pharmacological therapies f) Affected person/Household training together with preventive care g) Anticipatory steering for the go to (remember to embody precisely what you mentioned throughout the go to; Assessment Shiny Futures web site for this part) h) Comply with-up appointment with an in depth plan of f/u
CLINICAL CASE SCENARIO
A 5-year-old male affected person presents to your clinic for ear ache. His mom reviews he was in good spirits and energetic till about 5 days in the past when he developed an higher respiratory an infection (URI) consisting of clear nasal discharge and cough. The mom reviews that he has been torpid and stopped consuming fluids about 48 hours earlier than he developed a temperature of 102.1°F and began complaining that his proper ear harm. The mom denies nausea, vomiting, diarrhea, headache, or change in urine output. The mom reviews that the affected person’s sleep was interrupted on account of his complaints of proper ear ache. She observed that he tugged at his proper ear steadily whereas remaining minimally inquisitive about taking part in together with his toys earlier within the day. Right now, his vitals are as follows: weight 40.5 lbs, peak 43.zero inches, BP 100/70, HR 100, RR 26, and Temperature is 102F.
Prognosis: Acute Otitis Media
As you develop your narrated PowerPoint, remember to handle the standards mentioned within the video above and the directions listed under:
FOLLOW THE TEMPLATE BELOW for the Medical Case Report – SOAP PowerPoint Project:
DO NOT INCLUDE THESE INSTRUCTIONS IN THE POWERPOINT. POINTS WILL BE DEDUCTED. REFER TO THE EXAMPLE CASE REPORT FOR GUIDANCE.
SUBJECTIVE (S): Describes what the affected person reviews about their situation. For INITIAL visits collect the information under from the medical situation and the textbook. DO NOT COPY AND PASTE THE SCENARIO; EXTRACT THE RELEVANT INFORMATION.
Historian (required; until the affected person is 16 y/o and older): doc identify and relationship of guardian Affected person’s Initials + CC (Identification and Chief Grievance): E.g. 6-year-old feminine right here for analysis of a palmar rash HPI (Historical past of Current Sickness): Bear in mind OLD CAARTS (onset, location, length, character, aggravating/assuaging components, radiation, temporal affiliation, severity) written in paragraph kind PMH (Previous Medical Historical past): Record any previous or current medical situations, surgical procedures, or different medical interventions the affected person has had. Specify what 12 months they came about MEDs: Record prescription medicines the affected person is taking. Embrace dosage and frequency if identified. Inquire and doc any over-the-counter, natural, or conventional treatments. Allergy symptoms: Record any allergy symptoms the affected person has and point out the response. e.g. Medicines (tetracycline-> shortness of breath), meals, tape, iodine->rash FH (Household Historical past): Record related well being historical past of quick household: grandparents, mother and father, siblings, or youngsters. e.g. Inquire about any heart problems, HTN, DM, most cancers, or any lung, liver, renal illness, and so forth… SHx (Social historical past): doc mum or dad’s work (present), instructional stage, dwelling state of affairs (renting, homeless, proprietor), substance use/abuse (alcohol, tobacco, marijuana, illicit medication), firearms in-home, relationship standing (married, single, divorced, widowed), variety of youngsters within the residence (in SF or overseas), how just lately pt immigrated to the US and from what nation of origin (if relevant), the gender of sexual companions, # of companions in final 6 mo, vaginal/anal/oral, protected/unprotected.
Affected person Profile: Actions of Day by day Residing (age-appropriate): (embody feeding, sleeping, bathing, dressing, chores, and so forth.), Modifications in daycare/faculty/after-school care, Sports activities/bodily exercise, and Developmental Historical past: (present a historical past of growth over the kid’s lifespan. If a baby is 1y/o or youthful, present delivery historical past additionally)
HRB (Well being-related behaviors): ROS (Overview of Programs): Asking about issues by organ system systematically from head-to-toe. Included traditional related signs (this contains pertinent negatives and positives).
OBJECTIVE: Bodily findings you observe or discover on the examination. 1. Age, gender, basic look 2. Vitals – HR, BP, RR, Temp, BMI, Peak & Percentile; Weight & Percentile, Embrace the Development Chart three. Bodily Examination: observe pertinent positives and negatives (discuss with the textbook for traditional findings associated to current grievance and the prognosis you consider the affected person has) four. Lab Part – what outcomes do you’ve gotten? 5. Research/Radiology/Pap Outcomes Part – what outcomes do you’ve gotten?
RISK FACTORS: Record danger components for the acute and persistent situations
ASSESSMENT: What do you suppose is happening primarily based on the medical case situation? That is primarily based on the case. You might be to record the acute prognosis and three differential diagnoses, so as of what’s seemingly, potential, and unlikely (embody supporting info that helped you to reach at these differentials). You could embody the ICD-10 codes, the definition for the acute and differential diagnoses, and the pertinent positives and negatives of every prognosis.
You might be to additionally record any persistent situations with the ICD-10 codes.
NATIONAL CLINICAL GUIDELINES: Record the rules you’ll use to information your therapy and administration plan
TREATMENT & MANAGEMENT PLAN: Quantity issues (E.g. 1. HTN, 2. DM, three. Knee sprain), use bullet factors, and embody A – F under for every prognosis and G – H after you’ve addressed all situations.
Instance:
1. HTN a) Vaccines administered this go to & vaccine administration types given, b) Treatment-include dosage quantities and mg/kg for drug and variety of days, c) Laboratory checks ordered d) Diagnostic checks ordered e) Non-pharmaceutical therapies f) Affected person/Household training together with preventive care
2. HLD a) Vaccines administered this go to & vaccine administration types given, b) Treatment-include dosage quantities and mg/kg for drug and variety of days, c) Laboratory checks ordered d) Diagnostic checks ordered e) Non-pharmaceutical therapies f) Affected person/Household training together with preventive care Additionally mentioned: g) Anticipatory steering for subsequent well-child go to (remember to embody precisely what you mentioned throughout the go to; Assessment Shiny Futures web site for this part) Return to the clinic: h) Comply with-up appointment with an in depth plan for f/u and any referrals
