SOAP note- PCOS

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Home>Homework Answsers>Nursing homework helpnotesPlease see the attachment for instructions2 years ago03.10.202330Report issuefiles (1)SOAPPolycysticOvarianSyndromeInstructions.docxSOAPPolycysticOvarianSyndromeInstructions.docxDelete all text in red – these are instructions and not part of the SOAP document.Prompt:Patient is here for visit because they have Polycystic Ovarian SyndromeRequirement:APA formatIntext citationReferences at least 4 high-level scholarly reference per post within the last 5 years in APA format.EACH differential diagnostic gets 1 referencePlagiarism free.Turnitin receipt.Note: ADDITIONAL ASSIGNMENT: Please include a one page paper discussing this SOAPnote for a case presentation about it.Example when I was doing my clinical rotations in ob/gyn last week I found and interested case of a female patient with polycystic ovarian syndrome(PCOS) and bla, blab la you can be creative and make any interesting stories………ID:Client’s Initials*:MR Age: 34 Race: hispanic Gender: female Date of Birth:Marital Status: single*It is recommended to include false initials and use Jan 1, XXXX (correct year) to protect patient confidentiality. Include brief statement on whether the patient came to the clinic alone or accompanied, and if so by whom, and whether they are a reliable historian.Subjective:CC:“my periods are irregular and painful”HPI:In paragraph format, including at the minimum OLDCARTS. Please start with demographics: AA, a 29 y.o. Asian female presents to the clinic alone with complaint of _____________.Onset, Location, Duration, Characteristics/context, Aggravating factors or Associated symptoms, Relieving Factors, Treatment, and Timing, Severity. Include any pertinent positives or negatives.Past Medical History:· Medical problem list· Preventative care: (if applicable to the case – Paps, mammography, colonoscopy, dates of last visits, etc.)· Surgeries:· Hospitalizations:· LMP, pregnancy status, menopause, etc. for womenAllergies:Food, drug, environmentalMedications:include names, doses, frequency, and routes, and reason in parenthesis if off-label or secondary useFamily History:Social History:-Sexual history and contraception/protection (as applies to the case)-Chemical history (tobacco/alcohol/drugs) (ask every pt about tobacco use)Other:-Other social historyas applicable to each case(diet/exercise, spirituality, school/work, living arrangements, developmental history, birth history, breastfeeding, ADLs, advanced directives, etc. Exercise your critical thinking here – what is pertinent and necessary for safe and holistic care)ROS(write out by system):Comprehensive (>10) ROS systems for wellness exams or complex cases only. Do not include all 14 systems for every SOAP unless needed – review and document thepertinent systems.Do not include diagnoses – those belong in PMH. The below categories are per CMS guidelines.Constitutional:Cardiovascular:Pulmonary:Gastrointestinal:Genitourinary:Integumentary & breast:Neurological:Psychiatric:Endocrine:Allergic/Immunologic:ObjectiveVital Signs: HR BP Temp RR SpO2 PainHeight Weight BMILabs, radiology or other pertinent studies: be sure to include the date of labs – might be POC tests from todayPhysical Exam(write out by system):Start with a general survey:Assessment(you will often have more than one diagnosis/problem, but do the differential on the main problem)Differentials (with a brief rationale for each include ICD-10): WITH REFERENCES1-Polycystic ovarian syndrome2- Hypothyroidism3- Cushing’s SyndromeInmunization Encounter for immunizationICD Z23It is recommended that adults receive a single dose of Tdap and followed by Td or a Tdapbooster every 10 years (Centers for Disease control and Prevention [CDC], 2020). Patientis updated with immunizations except for Tdap.4- Encounter for immunization5- ICD Z236- It is recommended that adults receive a single dose of Tdap and followed by Td or a Tdap7- booster every 10 years (Centers for Disease control and Prevention [CDC], 2020). Patient8- is updated with immunizations except for Tdap.3.DiagnosisPlan(4 pronged-plan for each problem on the problem list)Diagnostics:Treatment: medication needs referenceEducationFollow Up:List plan under each Diagnosis.Example1: Hypertension (I10)A: Lisinopril/HCT 20/12.5 Daily #90, refills 3B: BMP in 6 monthsC: Recheck BP in 2 WeeksD: Low Sodium Diet and lifestyle modifications discussed2: Morbid Obesity BMI XX.X (E66.01)A: Goal of 5% weight reduction in 3 monthsB: Increase exercise by walking 30 minutes each dayC: Portion Size Education3: T2 Diabetes with diabetic neuropathy (E11.21)A: Repeat A1C in 3 monthsB. Increase Metformin to 1000mg BID #180, refills: 3C: Annual referral to diabetic educator, ophthalmology, and podiatry (placed X/X)D: Daily blood glucose check in the am and when sickE. Return to clinic in 3-4 months to reassessSOAPPolycysticOvarianSyndromeInstructions.docxDelete all text in red – these are instructions and not part of the SOAP document.Prompt:Patient is here for visit because they have Polycystic Ovarian SyndromeRequirement:APA formatIntext citationReferences at least 4 high-level scholarly reference per post within the last 5 years in APA format.EACH differential diagnostic gets 1 referencePlagiarism free.Turnitin receipt.Note: ADDITIONAL ASSIGNMENT: Please include a one page paper discussing this SOAPnote for a case presentation about it.Example when I was doing my clinical rotations in ob/gyn last week I found and interested case of a female patient with polycystic ovarian syndrome(PCOS) and bla, blab la you can be creative and make any interesting stories………ID:Client’s Initials*:MR Age: 34 Race: hispanic Gender: female Date of Birth:Marital Status: single*It is recommended to include false initials and use Jan 1, XXXX (correct year) to protect patient confidentiality. Include brief statement on whether the patient came to the clinic alone or accompanied, and if so by whom, and whether they are a reliable historian.Subjective:CC:“my periods are irregular and painful”HPI:In paragraph format, including at the minimum OLDCARTS. Please start with demographics: AA, a 29 y.o. Asian female presents to the clinic alone with complaint of _____________.Onset, Location, Duration, Characteristics/context, Aggravating factors or Associated symptoms, Relieving Factors, Treatment, and Timing, Severity. Include any pertinent positives or negatives.Past Medical History:· Medical problem list· Preventative care: (if applicable to the case – Paps, mammography, colonoscopy, dates of last visits, etc.)· Surgeries:· Hospitalizations:· LMP, pregnancy status, menopause, etc. for womenAllergies:Food, drug, environmentalMedications:include names, doses, frequency, and routes, and reason in parenthesis if off-label or secondary useFamily History:Social History:-Sexual history and contraception/protection (as applies to the case)-Chemical history (tobacco/alcohol/drugs) (ask every pt about tobacco use)Other:-Other social historyas applicable to each case(diet/exercise, spirituality, school/work, living arrangements, developmental history, birth history, breastfeeding, ADLs, advanced directives, etc. Exercise your critical thinking here – what is pertinent and necessary for safe and holistic care)ROS(write out by system):Comprehensive (>10) ROS systems for wellness exams or complex cases only. Do not include all 14 systems for every SOAP unless needed – review and document thepertinent systems.Do not include diagnoses – those belong in PMH. The below categories are per CMS guidelines.Constitutional:Cardiovascular:Pulmonary:Gastrointestinal:Genitourinary:Integumentary & breast:Neurological:Psychiatric:Endocrine:Allergic/Immunologic:ObjectiveVital Signs: HR BP Temp RR SpO2 PainHeight Weight BMILabs, radiology or other pertinent studies: be sure to include the date of labs – might be POC tests from todayPhysical Exam(write out by system):Start with a general survey:Assessment(you will often have more than one diagnosis/problem, but do the differential on the main problem)Differentials (with a brief rationale for each include ICD-10): WITH REFERENCES1-Polycystic ovarian syndrome2- Hypothyroidism3- Cushing’s SyndromeInmunization Encounter for immunizationICD Z23It is recommended that adults receive a single dose of Tdap and followed by Td or a Tdapbooster every 10 years (Centers for Disease control and Prevention [CDC], 2020). Patientis updated with immunizations except for Tdap.4- Encounter for immunization5- ICD Z236- It is recommended that adults receive a single dose of Tdap and followed by Td or a Tdap7- booster every 10 years (Centers for Disease control and Prevention [CDC], 2020). Patient8- is updated with immunizations except for Tdap.3.DiagnosisPlan(4 pronged-plan for each problem on the problem list)Diagnostics:Treatment: medication needs referenceEducationFollow Up:List plan under each Diagnosis.Example1: Hypertension (I10)A: Lisinopril/HCT 20/12.5 Daily #90, refills 3B: BMP in 6 monthsC: Recheck BP in 2 WeeksD: Low Sodium Diet and lifestyle modifications discussed2: Morbid Obesity BMI XX.X (E66.01)A: Goal of 5% weight reduction in 3 monthsB: Increase exercise by walking 30 minutes each dayC: Portion Size Education3: T2 Diabetes with diabetic neuropathy (E11.21)A: Repeat A1C in 3 monthsB. Increase Metformin to 1000mg BID #180, refills: 3C: Annual referral to diabetic educator, ophthalmology, and podiatry (placed X/X)D: Daily blood glucose check in the am and when sickE. Return to clinic in 3-4 months to reassessBids(81)Dr. Ellen RMMISS HILLARY A+abdul_rehman_Emily ClareSTELLAR GEEK A+Prof Double RSheryl HoganFortifiedProWritingGuruYoung NyanyaJahky BDr. Adeline ZoeDr M. 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