If this was the actual chart, you would and could not chart that the documentation for the questions asked as would be the same as the other patient in asking questions it is an individual chart. I need to have more than one differential diagnosis for each patient. You need to have 3 to rule two out to result your primary diagnosis. Dont forget to have your references as evidence based peer reviewed journals.
this SOAP Note needs to be answered with SOAP put in the paper and with ONLY 4 scholar references not later than 5 years!!!! to base your findings this is not on a real person but has to meet the criteria and references have to be within 5 years no later and I want APA format 6th edition PLEASE FOLLOW THE FILE I UPLOAD AS THEY ARE TO HELP YOU IN THIS PAPER. PLEASE READ WHAT IS A SCHOLARLY SOURCE it will help you. “””””Employ to be supported by evidence from the scholarly literature that is utilized by the practitioner (MD, NP, PA, etc.), NOT the general public. Do not support a decision using information from patient-geared sources (i.e. mayoclinic.org, WebMD, etc.).””””””””One more thing I want each of you to learn and remember going forward:
“Review of systems is what they say, physical exam is what you see.”
(This paper will be check to make sure its not plagiarizer) USE SOAP NOTE FORMAT and OLD CHART to format paper…………………………………….
Please follow my instructions to a T and the program outcomes as well as the grading rubric………….Thank you
Please view the power point presentation on Prescription Writing and write your medication regimen as you would write a prescription. What is your education regimen, follow up, and referral if necessary for both patients? Please be sure to support these with references as well.
Answer this case study and make sure you read the format soap that is how the paper is to be in format!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!
PBL Case Discussion Part One (graded)
PBL Case Discussion Part One (graded)
Setting: large urban city
Family practice clinic that employs physicians and nurse practitioners
Its been a fairly easy morning at your family practice site today. You move to the chart holder to get the chart for your next patient, Julia E, who presents with the chief complaint of headache.
HPI: Julia is a 14-year-old young lady who presents with her mother. Julia is sitting on the exam table and is playing on her phone. She does not look up when you enter. Her mother Cathy rises from the chair to greet you. Julia looks up and smiles but returns to looking at the phone until her mother asks her to put the phone away. Julia appears her stated age and is well groomed. Though her mother is present, you pull up your exam stool in front of Julia to ask her why she is her today. “I get headaches, sometimes they last for days. Mom says all the time I spend on the computer and looking at my phone is causing them, but I think it helps distract me from the pain.”
PMHx: Julias mother reports her overall health as good.
Childhood/previous illnesses: None
Chronic illnesses: None
Immunizations: Childhood immunizations UTD. Receives the flu shot every year
Blood transfusions: None
Denies ETOH, tobacco, illicit drugs
Sleep: Sleeps 5 to 6 hours a night. States “I cant fall asleep.”
Current medications: None LMP 1 week ago
Social Hx: Good student. Lives with parents and older sister and younger brother
Family Hx: Mother no health problems, father bipolar and well controlled. Siblings in good health. MGM and PGM deceased from breast CA. MGF deceased: lung CA. PGM alive, 85, overall health good. Has Type 2 diabetes.
Discussion Questions Part One:
What further questions do you have for Julia at this visit?
What is your differential diagnosis list for this visit thus far with rationale?
Based on your differential diagnoses list, identify what body systems youd examine along with pertinent positive/negatives in each system and any diagnostic tests you would like to perform?