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Clinical Reasoning and the Physical Assessment (graded) Using...

Clinical Reasoning and the Physical Assessment (graded)

Using course materials, textbooks, and the SOAP Note Format document provided in the Course Resource area of the course, choose a friend, colleague, or family member and perform a complete history on your “patient” that presents for a history and physical examination.  This is the kind of history you might obtain from a new patient, or during an annual well visit exam. You should devise a chief complaint so that you may document the OLDCART (HPI) data.  You must use the chief complaint of fatigue, fever, or muscles aches. 

You should include a complete ROS and all the other components of a complete patient history. This week you will only need to document the subjectiveportion of the SOAP note (not objective). Document your findings in a systematic manner and identify some of the key components of the history that may tip you off to primary care interventions that this patient may require. Share these findings in this discussion.  

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SOAP Note Format Patient Information: Initials, Age, Sex, Race, Insurance S. CC (chief complaint) a BRIEF statement identifying why the patient is here - in the patient’s own words - for instance "headache", NOT "bad headache for 3 days”. HPI : include all the information regarding the CC using the OLDCART format. If the CC was “Unintentional weight loss”, the OLDCART for the HPI might look like the following example: Onset: 2 months ago Location: Generalized Duration: Steady weight loss, 3-5 pounds per week Characteristics: Associated with feeling tired, poor appetite, and occasional nausea without vomiting Aggravating Factors: Food smells increase the frequency of nausea Relieving Factors: Small, bland meals are better tolerated Treatment: None reported Current Medications : include dosage, frequency, length of time used and reason for use; also include OTC or homeopathic products. Allergies: include medication, food, and environmental allergies separately. PMHx : include immunization status (note date of last tetanus for all adults), past major illnesses and surgeries. Depending on the CC, more info is sometimes needed Soc Hx : include occupation and major hobbies, family status, tobacco & alcohol use, any other pertinent data. Always add some health promo question here - such as whether they use seat belts all the time or whether they have working smoke detectors in the house. Fam Hx : illnesses with possible genetic predisposition, contagious or chronic illnesses. Reason for death of any deceased first degree relatives should be included . Include parents, grandparents, siblings, and children. Include grandchildren if pertinent.
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SOAP Note Format.docx
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