Health Medical Homework Help

60 yr old female presents to your clinic after a syncopal episode few days ago. Her husband found pt lying on the floor. Pt does not have any recollection of the fall. Did not seek care at ER since she was ” fine”. Denies any changes in her after the episode.

PMH: HTN, DM Type 2, Hyperlipidemia, Hypothyroidism

Meds: 

Lisinopril 20 mg one tab po daily for hypertension

Metformin 500 mg one tab po twice a day for Diabetes

Atorvastatin 20 mg one tab po at bed time for hyperlipidemia

Levothyroxine 50 mcg one tab po daily for hypothyroidism

1. Write a hypothetical SOAP note based on the above chief complain. Is the patient safe to drive? What clearance does she need?

2. Document detailed HEENT, Neuro, and cardiac PE exam findings on SOAP note.

3. Write a substantive response to a minimum of two different students. Is objective and subjective data included in the right format? Please be specific to information related to the SOAP note format.

Is objective and subjective data included in the right format? Please be specific to information related to the SOAP note format.

Would you agree with your peers differentials listed? Are there any diffs you would add/remove, if so explain your rationale.

Does HPI have relevant information related to CC?

Medication listed with right timing, dosing, and number of tablets specified? Any red flags with medication list? 

PMH, FH, and SH has all the appropriate information?

Does information in ROS correlate to CC?

1. Is there any information lacking in physical exam documentation of CC (Students often get confused between ROS and objective findings)?
2. Includes assessment, plan, follow up information, and patient education?
3. See attached sample SOAP Note: Sample_ SOAP_ Note
4. 20 points will be deducted for combining subjective and objective information. Please see example below:
5. ROS:
6. Example 1. 

General: Alert and oriented, denies fatigue and chills.

1. ( subjective and objective information is combined above. ” Alert and oriented” is part of PE general and not ROS.

Example 2.

ROS:

Resp: denies cough, wheezing,  lungs sounds CTA bilaterally.

( subjective and objective is combined above;” lungs sounds CTA bilaterally” is part of PE

PE:

Example 1:

PE: Denies fatigue and chills. Alert and oriented.

” Denies fatigue and chills” is part of ROS and not PE.

Example 2:

PE: Bowel sounds present all quadrants. Denies abdominal pain.

” Denies abdominal pain” is part of ROS and not PE