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Presentation/PPT
27/08/2022
Select a patient that you examined during the last four weeks. With this patient in mind, address the following in a SOAP Note:
(THE TOPIC HERE IS URINARY TRACT INFECTION (UTI) )
please use this format
Comprehensive SOAP Template
Patient Initials: Age: Gender: F
Introduction –Purpose:
SUBJECTIVE DATA:
Chief Complaint (CC):
History of Present Illness (HPI):
Medications:
Allergies: Seafood, iodine
Past Medical History (PMH):
Past Surgical History (PSH): Denies.
Sexual/Reproductive History (Obstetric):
Personal/Social History:
Immunization History and Preventive Care:
Significant Family History:
.
Review of Systems:
General:
HEENT:
Respiratory:
Cardiovascular:
Breasts:
Gastrointestinal:
Genitourinary:
Musculoskeletal:
Psychiatric:
Neurological:
Dermatological:
Hematological and Lymphatic:
Endocrine:
Allergy and Immunology:
OBJECTIVE DATA:
Physical Exam:
Vital signs:
General appearance:
HEENT:
Neck:
Lymphatics:
Breasts:
Chest:
Heart:
Abdomen:
Neurological:
Musculoskeletal:
Extremities:
Skin:
Labs, X-rays, and Diagnostics
ASSESSMENT:
Priority Diagnosis
Differential Diagnosis
For each priority diagnosis, list at least three differential diagnoses, each of which must be supported with evidence and guidelines. For holistic care, you need to include previous diagnoses and indicate whether these are controlled or not controlled. These should also be included in your treatment plan.
PLAN:
Treatment Plan: If applicable, include both pharmacological and non-pharmacological strategies, alternative therapies, follow-up recommendations, referrals, consultations, and any additional labs, x-ray, or other diagnostics. Support the treatment plan with evidence and guidelines.
Health Promotion: Include exercise, diet, and safety recommendations, as well as any other health promotion strategies for the patient/family. Support the health promotion recommendations and strategies with evidence and guidelines.
Disease Prevention: As appropriate for the patient’s age, include disease prevention recommendations and strategies such as fasting lipid profile, mammography, colonoscopy, immunizations, etc. Support the disease prevention recommendations and strategies with evidence and guidelines.
REFLECTION:Reflect on your clinical experience, and consider the following questions: What did you learn from this experience? What would you do differently? Do you agree with your preceptor based on the evidence?
References
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