Episodic SOAP Note

Category: Nursing

S. S. 65-year-old Indian female present to the office with c/o back pain and left hip severe painHx R breast CA treated with chemo and Radiation, HTN CAD CHF Hypothyroid COPD afib TIA and recent insomnia hx of fallsMedscoumadinmetoprololLasixLevothyroxineColaceentrestotramadol 25mg BID PRN pain (pt reported this dose is not working)trazadone mg QHSSx hx hysterectomy, R breast mastectomy,Bone density scan was done Dx osteopeniaTreatment Fosamax Q weeklyIncrease tramadol 50mg BID PRN painEpisodic Visit: Musculoskeletal Focused NoteFor this Assignment, you will work with a patient with a musculoskeletal condition that you examined during the last three weeks. You will complete your third Episodic/Focused Note Template Form for this course where you will gather patient information, relevant diagnostic and treatment information as well as reflect on health promotion and disease prevention in light of patient factors such as age, ethnic group, previous medical history (PMH), socio-economic, cultural background, etc. In this week’s Learning Resources, please review the Focused Note resources for guidance on writing Focused Notes..To prepare:• Use the Episodic/Focused Note Template found in the Learning Resources for this week to complete this assignment.• Select a patient that you examined during the last three weeks based on musculoskeletal conditions. With this patient in mind, address the following in a Focused Note:Assignment:• Subjective: What details did the patient provide regarding her personal and medical history?• Objective: What observations did you make during the physical assessment?• Assessment: What were your differential diagnoses? Provide a minimum of three possible diagnoses. List them from highest priority to lowest priority. What was your primary diagnosis and why?• Plan: What was your plan for diagnostics and primary diagnosis? What was your plan for treatment and management, including alternative therapies? Include pharmacologic and nonpharmacologic treatments, alternative therapies, and follow-up parameters as well as a rationale for this treatment and management plan.• Reflection notes: What would you do differently in a similar patient evaluation?

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