ASSIGNMENT HELP | Discussion 2 Advanced Health/Physical Assessment

Evaluate and critique a SOAP note for completeness and thoroughness.
1.Review this sample SOAP note . Explain what needs to be done to improve this note and why. Be sure and identify the following:

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.Eight (8) or more data points in the subjective history that need improvement
.Seven (7) or more data points in the objective history that need improvement
.For each diagnosis or differential diagnosis identified, is the pertinent positive and negative data thorough and accurate?
2.Your response should contain a discussion of National Guidelines and ARHQ Health Promotion recommendations (according to the United States Preventative Task Force [USPTF]) appropriate to the case.
3.Your response should contain a minimum of 300 words and follow APA formatting and citation.

MODEL ANSWER

What Need to Be Done to Improve the Soap Note

Eight (8) or more data points in the subjective history that need improvement

The following is the identified subjective history that needs improvement:

1. Chest pain experienced during coughing.
2. Chest pain.
3. Shortness of breath on exertion, chest tightness, cough,
4. For throat pain.
5. Tenderness and facial pain.
6. Nasal congestion and yellow nasal discharge.
7. Ear congestion.
8. Eye pressure.
9. Fever chills and weakness.
10. Denial of regular exercise.
11. Generalized body aches such as head, chest, and abdomen aches.

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Seven (7) or more data points in the objective history that need improvement

1. Tender right and right cervical lymph node.
2. Tonsil that is slightly edematous bilaterally.
3. An erythematous pharynx.
4. Nasal turbinates are edematous and erythematous.
5. tympanic membrane erythematous
6. temperature 99.3
7. weight 230 lbs

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For each diagnosis or differential diagnosis identified, is the pertinent positive and negative data thorough and accurate?

Pertinent positives are disease specific and are used in ruling in a | PLACE YOUR ORDER NOW AT writtask.com | osis. On the other hand, the relevant negatives call for more creative and analytical thinking gleaned from the differential functioning and diagnosis to rule out the possibilities of specific | PLACE YOUR ORDER NOW AT writtask.com | positives, such as the Acute Maxillary Sinusitis with the viral syndrome, are probably based on the PE from the differential diagnosis (CDC, 2020). There is thorough and accurate data to support this positive pertinent since it is based on the recent patient history on influenza, sore throat, halitosis, eye pressure, headache, and | PLACE YOUR ORDER NOW AT writtask.com | can also be contributed by other diagnostic factors, including; cough, nasal congestion, fever, and maxillary sinus pain (CDC, 2020). However, the diagnosis of pertinent positives does not seem thorough; although | PLACE YOUR ORDER NOW AT writtask.com | that the possibilities of streptococcal pharyngitis are possible based on the PE and the patient’s history. However, the rapid test results confirm that it was negative, which qualifies it as a pertinent | PLACE YOUR ORDER NOW AT writtask.com | pharyngitis is a strep throat; this is a type of infection that affects the back of the throat, including tonsils, and it is caused by a group | PLACE YOUR ORDER NOW AT writtask.com | associated with it include; vomiting, nausea, and headache. It is also related to the enlargement of lymph nodes in the neck, red tonsils, sore throat. 

Infectious mononucleosis is a perti | PLACE YOUR ORDER NOW AT writtask.com | and diagnosed. The possibility or positivity of this diagnosis is based on the PE and the history of the patient. It includes diagnostic such as fatigue, weakness, loss of | PLACE YOUR ORDER NOW AT writtask.com | is pertinent since the possibility is thoroughly and accurately enumerated, and the diagnosis is conducted | PLACE YOUR ORDER NOW AT writtask.com | with the positivity of cough, fever, diarrhea, fatigue, abdominal cramps. All these diagnoses indicate the positivity of adenovirus infection.

Further, the meningitis possibilities are negative pertinent; based on the diagnosis and the patient’s history and PE, the chance of meningitis | PLACE YOUR ORDER NOW AT writtask.com | States Preventative Task Force (USPTF), the diagnosis is made to identify the risk factors that predispose the patient to certain risk factors that increase the chances of a given health condition or | PLACE YOUR ORDER NOW AT writtask.com | conducted according to the recommendations of USPTF, including the recommended test (AHRQ, 2020).

References

AHRQ. (2020). U.S. Preventive Services Task Force (USPSTF). Ahrq.gov. Retrieved from https://www.ahrq.gov/prevention/guidelines/guide/section2.html.

CDC. (2020). Group A Strep | Strep Throat | For Clinicians | GAS | CDC. Cdc.gov. Retrieved 11 January 2021, from https://www.cdc.gov/groupastrep/diseases-hcp/strep-throat.html.

Packer C.D. (2019) Pertinent Positives and Negatives. In: Presenting Your Case. Springer, Cham. https://doi.org/10.1007/978-3-030-13792-2_5