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Walden University Nursing Episodic Focused SOAP Note

 

Case Study #2-

47-year-old obese female complains of pain in her right wrist, with tingling and numbness in the thumb and index and middle fingers for the past 2 weeks. She has been frustrated because the pain causes her to drop her hair-styling tools

  • Also, your Case Study Assignment should be in the Episodic/Focused SOAP Note format rather than the traditional narrative style format. Refer to Chapter 2 of the Sullivan text and the Episodic/Focused SOAP Template in the Week 5 Learning Resources for guidance. Remember that all Episodic/Focused SOAP notes have specific data included in every patient case.

With regard to the case study you were assigned:

  • Review this week’s Learning Resources, and consider the insights they provide about the case study.
  • Consider what history would be necessary to collect from the patient in the case study you were assigned.
  • Consider what physical exams and diagnostic tests would be appropriate to gather more information about the patient’s condition. How would the results be used to make a diagnosis?
  • Identify at least five possible conditions that may be considered in a differential diagnosis for the patient.

when you answer this part of the focused assessment: [Diagnostic results ‘]you have to include the answer to this question:

  • Consider what physical exams and diagnostic tests would be appropriate to gather more information about the patient’s condition. How would the results be used to make a diagnosis?