ASSIGNMENT HELP | Patient initial (one initial only), age, and gender must be HIPAA compliant

Demographic Data

Patient initial (one initial only), age, and gender must be HIPAA compliant
Subjective

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Chief Complaint (CC)
History of Present Illness (HPI) in paragraph form (remember OLDCART: Onset, Location, Duration, Characteristics, Aggravating/Alleviating Factors, Relieving Factors, Treatment)
Past Med. Hx (PMH): Medical or surgical problems, hospitalizations, medications, allergies, immunizations, and preventative health maintenance as applicable
Family Hx: As applicable
Social Hx: Including nutrition, exercise, substance use, sexual hx, occupation, school, etc.
Review of Systems (ROS) as appropriate: Include health maintenance (e.g., eye, dental, pap, vaccines, colonoscopy)
Objective

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Vital signs
Physical findings listed by body systems, not paragraph form
Assessment (Diagnosis/ICD10 Code)

Include all diagnoses that apply for this visit
Plan

Dx Plan (lab, x-ray)
Tx Plan: (meds)
Pt. Education, including specific medication teaching points
Referral/Follow-up
Health maintenance (including when screenings, immunizations, etc., are next due):
*based on population focus, some additional details may be required by faculty

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# Case Example :46-year-old Mexican American Female presented today with her husband complains palpitation, fluttering in chest with dizziness for 2 weeks on and off. States, the symptom occurred 3 to 5 time a week and last long 10-15 mins per episode. She denies chest pain, headache, and other symptoms. The symptom was better when she relax and worsen while she has activity. She denies any medication. She also denies any medical problems.
V/S : BP 106/68, HR 72/ mins, RR 16/ mins T: 98 F
Weight 155 lbs Hight 5\’2\’\’
*** You can look it up an example of mini SOAP note in Course Hero*** and you makeup the rest of paper.

MODEL ANSWER

LZ is a 40-year-old African-American female who presents herself to the clinical setting with complaint of “stomach pain.” The sharp epigastric pain started 4 days ago and has been persistent although it doesn’t radiate. On the pain scale, she reports a severity of 9/10. This has been the very first occurrence. She reports to experience diarrhea, anorexia and vomiting. However, she denies having fever, weakness, nausea or | PLACE YOUR ORDER NOW AT writtask.com | denies having shortness of breath, dyspepsia, melena and | PLACE YOUR ORDER NOW AT writtask.com | was on 24/5/21. She has tried Pepto-Bismol but there has been no relief.

For past medical history, she has had Ovarian Cyst, Appendicitis, Gallstones, reports of very irregular menses | PLACE YOUR ORDER NOW AT writtask.com | history includes an appendectomy and cholecystectomy. In terms of allergy, there are no known allergic reactions.

Medications: Patient used acetaminophen or Tylenol; 325 mg1-2 tablets specifically for back pain.

Family history: No known family history condition

Social History: Used tobacco but denies EtOH

Review of systems: The review of system shows that the patient doesn’t have any problem with the eyes as well as the dental. Generally, the patient’s condition is not very | PLACE YOUR ORDER NOW AT writtask.com | is 99.0 F, BP is 126/8 mmHg, Height is 67 in, weight 150lb and the BMI is 23.5.

General observation: The is slender, neatly groomed, alert as well as cooperative during the assessment process. She holds her abdomen often demonstrating some level of | PLACE YOUR ORDER NOW AT writtask.com | is warm and moist with good turgor besides being Noncitric.  

HEENT: The patient reports symmetrical OU. There is no strabismus | PLACE YOUR ORDER NOW AT writtask.com | reports to be white as well as nonicteric. The conjunctiva and the cornea look clear.

The Mouth: The oral mucosa is pink and it is well hydrated. There are no masses or lesions.

CV: RRR. The S1 and S2 are | PLACE YOUR ORDER NOW AT writtask.com | reported, S3 and S4, there are friction rubs and there is reported splitting of heart sounds.

Pulm: There is no wheezing from the chest as the chest expansion is | PLACE YOUR ORDER NOW AT writtask.com | rales and dullness.

Abdomen: Abdomen is flat, | PLACE YOUR ORDER NOW AT writtask.com | experiences notable pain from the lower abdominal region. Experiences ender to light and then deep palpations at the epigastric region.

Differential diagnosis

The patient presents with epigastric pain, vomiting, diarrhea as well as anorexia | PLACE YOUR ORDER NOW AT writtask.com | condition is | PLACE YOUR ORDER NOW AT writtask.com | conditions include hepatitis, pancreatitis, ectopic pregnancy and myocardial infarction.

Labs

R/O: Pregnancy

Qualitative Beta-HCG with reflex

Troponin

Urine culture

CBC, BMP, Bilirubin (total, direct and indirect).

Imaging tests

EKG, R/O:MI

Patient education

Since the patient is likely to have gastroenteritis, it is important that they drink a lot of fluids and get a | PLACE YOUR ORDER NOW AT writtask.com | should also be advised not to consume alcohol or | PLACE YOUR ORDER NOW AT writtask.com | eating or drinking, the patient should drink fluids slowly, in frequent as well as small amounts to reduce the risks of | PLACE YOUR ORDER NOW AT writtask.com | aspect in the patient education is for the patient to avoid taking medications that contain ibuprofen or aspirin as they may easily cause irritation to the | PLACE YOUR ORDER NOW AT writtask.com | patient should be advised not to take medications by mouth unless the medical care provider has advised as so.

Referral/Follow-up Make a follow-up to understand other possible complications to screen for other conditions such as cancer screening and…