Using the condition you posted about in DQ 1 this week, provide a SOAP note using the format outlined below. Support your summary and recommendations plan with a minimum of two APRN-approved scholarly resources. You may not select a condition or disorder that has already been profiled by another learner; you must select a different one.
Subjective
CC (Chief complaint)
HPT (History of present illness)
History (Pertinent medical, surgical, social, medications, exposure, family history, allergies, vaccines)
ROS (Review of systems)
Objective
Vital signs/BMI
Physical exam findings
Diagnostic results (include actual "results" or "findings" that you would expect for a certain scenario)
Assessment/Plan
Differential list and rationale for final/working diagnosis
Problem list
Plan for Each Problem
Based on evidence with proper references
Further diagnostic testing you would order
Nonpharmacologic therapy
Pharmacologic therapy, including specific medication dose
Frequency and duration of therapy
Patient education
Follow-up
Document patient’s surgical history – including complications/issues with anesthesia