Neurovascular SOAP

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Dear Writter : this is fictitious patient based my assignment of a video that I am recording.  I haved as much fictitious information.  Everything else can be added as appropriate.  

Please note Everything is normal for this pt aside from new onset of headaches. The most important part is the diferential diagnosis.  

Thank you.

 

  • Neurovascular SOAP
  • students will decide on the Chief Complaint (CC) which must be appropriate for the associated body system (no ER or ICU type CCs).
  • The student will complete all SOAP components
  • The Subjective section includes the following: ID (MD38,, 08/10/1984, Female, Hispanic,  Accompanied, and Historian), CC, Headaches, HPI new onset,  you can say pt uses glasses maybe new prescription. Stress/lack of sleep related to job stress, other made a diferential dx. no medical history (using OLDCARTS for problem-focused history), PMH, Family History (Breast CA Mother, HBP, Father Deceased as a child accident, Mothers parents, both die of natural causes, Fathers parents unknown), Social History (…), and ROS (problem-focused based on body system). 
  • Works in finances, married for 20 years, has a husband, 2 children aged 13, 15. LMP 2 weeks ago, uses protection. No smoke/no drugs, no allergies
  •  
  • The Objective section includes: expected vital signs and the physical examination documentation with detailed focus on the week’s body system (as well as general, and basic assessment of CV and Pulmonary).
  •  
  • The Assessment section must contain 3 differential diagnoses with rationale and in-text citations to credit the evidence-based sources used to defend the diagnosis choices. 
  • One of these three diagnoses must be the final or working diagnosis.
  • The Plan section is based on the working/ final diagnosis. This must include the five aspects of a plan which are diagnostics, treatments, education, referral (if applicable), and follow-up.
  •  The student should use in-text citations to credit their sources of information for each aspect of the plan.
  • The student must use a minimum of two references which should be recent (within the last 5, but up to 10 years if clinical practice guideline) and should be peer-reviewed.
  • Use APA title page, citations, and reference format.

Respectfully,