Description
Please fill out the SOAP note template in the attached files based on the scenario.
1. Please provide at least 1 scholarly reference with DOI for each diagnosis (last five years, 2019).
2. Write in bullet format same way as you did in the previous SOAP note.
3. I have already chosen the diagnosis, and I wrote them in the template. You just need to add the justification with citations.
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Name:
Section:
Week 5
Shadow Health Digital Clinical Experience Focused Exam: Cough Documentation
SUBJECTIVE DATA: Include what the patient tells you, but organize the information.
Chief Complaint (CC):
History of Present Illness (HPI):
Medications:
Allergies:
Past Medical History (PMH):
Past Surgical History (PSH):
Sexual/Reproductive History:
Personal/Social History:
Immunization History:
Significant Family History (Include history of parents, Grandparents, siblings, and children):
Review of Systems: From head-to-toe, include each system that covers the Chief Complaint,
History of Present Illness, and History). Remember that the information you include in this
section is based on what the patient tells you. You will only need to cover systems pertinent to
your CC, HPI (N/A, UNKNOWN is not acceptable, make up the information if you need to). To
ensure that you include all essentials in your case, refer to Chapter 2 of the Sullivan text.
General: Include any recent weight changes, weakness, fatigue, or fever, but do not
restate HPI data here.
HEENT:
Respiratory:
Cardiovascular/Peripheral Vascular:
© 2021 Walden University
Psychiatric:
Neurological:
Lymphatics:
OBJECTIVE DATA: From head-to-toe, include what you see, hear, and feel when doing your physical
exam. You only need to examine the systems that are pertinent to the CC, HPI, and History unless you
are doing a total H&P. Do not use WNL or normal. You must describe what you see.
Physical Exam:
Vital signs: Include vital signs, ht, wt, temperature, and BMI and pulse oximetry
General: Include general state of health, posture, motor activity, and gait. This may also include
dress, grooming, hygiene, odors of body or breath, facial expression, manner, level of conscience, and
affect and reactions to people and things.
HEENT:
Respiratory: Always include this in your PE.
Cardiology: Always include the heart in your PE.
Lymphatics:
Psychiatric:
Diagnostics/Labs (Include any labs, x-rays, or other diagnostics that are needed to develop the
differential diagnoses.)
ASSESSMENT:
Primary Diagnosis: Acute Viral Rhinitis
Differential Diagnosis:
1. Acute Sinusitis:
2. Influenza (Flu):
3. Ear Infection:
© 2021 Walden University
© 2021 Walden University
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