Please Read The Description Below And Attachments Then Des

Question

Please Read The Description Below And 2 Attachments Then Describe A C Please read the description below and 2 attachments. Then describe a condition in a few sentences, followed by a SOAP note of the condition (from any of the chapters in this module) using the format as described in your book and the links below and submit it under Discussions. This activity is designed to have you start learning and developing written documentation skills to inform other medical professionals about a particular patient/client’s signs, symptoms, assessment and treatment plan, or prior history/treatment. Please read the 2 attachments: 1. KNH 209 SOAP note template from Wikipedia to get an overall understanding of the process 2. My brief outline and sample of how to write a SOAP note Please write your SOAP note using at least 10 medical terms (underline each word you use) from the specialties in the chapters we are covering for this module. Please be accurate in your spelling and use of the words. If you have used a term correctly and in context, there is no need to give a definition of it in the sentence. While I understand you do not have the same clinical understanding or skills as a clinician, this activity is designed to show that you are integrating the information and can begin to formulate a possible scenario of a patient based on what you have learned. The Wikipedia example shows a lot of shortened formats of documentation. I would like you to write things out more clearly right now unless we have learned a particular abbreviation that you'd like to use (eg. SOB--shortness of breath) Be creative! (20 points for original post + 5 points each response to other students = 30 points in total)

Dr. Jack HW Helper · Accepted Answer

The following paper presents a comprehensive SOAP note based on a hypothetical patient experiencing symptoms related to a respiratory condition. The condition selected for this scenario is acute bronchitis, characterized by inflammation of the bronchial tubes leading to cough, sputum production, and dyspnea. The SOAP note aims to demonstrate clinical documentation skills by highlighting critical signs, symptoms, assessment findings, and treatment plan using appropriate medical terminology. Subjective The patient is a 45-year-old male presenting with a chief complaint of persistent cough for the past five days. He reports productive sputum that is yellow-green in color and describes increasing shortness of breath during exertion. He denies fever but notes mild chest tightness. The patient reports recent exposure to colleagues with respiratory infections and smoking history of 15 pack-years. No hemoptysis reported. He notes recent fatigue and some difficulty sleeping due to cough discomfort. Objective Temperature: 99.1°F (37.3°C) Heart rate: 88 bpm Respiratory rate: 20 breaths per minute Oxygen saturation: 96% on room air Chest auscultation: wheezing and coarse crackles heard over bilateral lung fields Palpation: No tenderness or masses Percussion: Resonant throughout Laboratory findings: Elevated white blood cell count, specifically an increase in neutrophils Assessment This patient's presentation is consistent with acute bronchitis, likely airborne viral etiology, given the viral onset of symptoms, absence of fever, and productive cough. Differential diagnoses include pneumonia and chronic obstructive pulmonary disease exacerbation, but the clinical picture does not strongly support these. The elevated white blood cell count suggests an inflammatory response. Absence of tonal changes on auscultation indicates no significant airway obstruction or lung consolidation. Plan Symptomatic treatment with humidified air and adequate hydration Patient education on avoiding ir

Please Read The Description Below And Attachments Then Des

Please Read The Description Below And 2 Attachments Then Describe A C

Paper For Above instruction

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