A 22-year-old female presents with a history of asthma and three days of increased wheezing and shortness of breath. She works at the local zoo during the summer to save money for the school year. Create a SOAP Note on this patient using evidence-based content. Using the information provided on the first paragraph on this patient along with content and resources provided in this course and in NURS 620. Also use patients you have encountered in the clinical setting as a guide. Utilize the typical clinical presentation for HPI, PMH and ROS. Include necessary components of the physical examination, diagnostic studies if appropriate, differential and actual diagnosis with treatment, follow-up, and education. Think about the pertinent negative and positive findings related to the diagnosis you are using.
Provide at least two citations at the end of the SOAP note for reference. SOAP Note Grading Criteria HPI, ROS, and PMH (meds/allergies, medical/surgical, and family/social): HPI: 4 or > elements identified; ROS: 4 >pertinent systems identified, with pertinent positives and negatives; PMH: >3 appropriate to history identified. Objective assessment is complete with relevant data and diagnostic testing. Problem Identification and Prioritization: Most problems are identified and rationally prioritized, final diagnosis is supported by subjective and objective findings. Treatment Plan (Including dose, route & freq): Treatment plan is appropriate, complete, follows appropriate guidelines and fully addresses the identified diagnosis/problem. Counseling, Referral, Monitoring & Follow-up: Patient education points, monitoring parameters, follow-up plan and referral plan (where applicable) is complete and clearly articulated.
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