Description
prepare 2 more SOAP notes 1. Acute pericarditis 2. Acute bacterial bronchitis
(Student Name)
Miami Regional University
Date of Encounter:
Preceptor/Clinical Site:
Clinical Instructor: Patricio Bidart MSN, APRN, FNP-C
Soap Note # ____ Main Diagnosis ______________
PATIENT INFORMATION
Name:
Age:
Gender at Birth:
Gender Identity:
Source:
Allergies:
Current Medications:
?
PMH:
Immunizations:
Preventive Care:
Surgical History:
Family History:
Social History:
Sexual Orientation:
Nutrition History:
Subjective Data:
Chief Complaint:
Symptom analysis/HPI:
The patient is ?
Review of Systems (ROS) (This section is what the patient says, therefore should state Pt
denies, or Pt states?.. )
CONSTITUTIONAL:
NEUROLOGIC:
HEENT:
RESPIRATORY:
CARDIOVASCULAR:
GASTROINTESTINAL:
GENITOURINARY:
MUSCULOSKELETAL:
SKIN:
Objective Data:
VITAL SIGNS:
GENERAL APPREARANCE:
NEUROLOGIC:
HEENT:
CARDIOVASCULAR:
RESPIRATORY:
GASTROINTESTINAL:
MUSKULOSKELETAL:
INTEGUMENTARY:
ASSESSMENT:
(In a paragraph please state ?your encounter with your patient and your
findings ( including subjective and objective data)
Example : ?Pt came in to our clinic c/o of ear pain. Pt states that the pain
started 3 days ago after swimming. Pt denies discharge etc? on examination I
noted this and that etc.)
Main Diagnosis
(Include the name of your Main Diagnosis along with its ICD10 I10. (Look at PDF example
provided) Include the in-text reference/s as per APA style 6th or 7th Edition.
Differential diagnosis (minimum 3)
–
–
PLAN:
Labs and Diagnostic Test to be ordered (if applicable)
?
–
?
–
Pharmacological treatment:
Non-Pharmacologic treatment:
Education (provide the most relevant ones tailored to your patient)
Follow-ups/Referrals
References (in APA Style)
Examples
Codina Leik, M. T. (2014). Family Nurse Practitioner Certification Intensive Review (2nd ed.).
ISBN 978-0-8261-3424-0
Domino, F., Baldor, R., Golding, J., Stephens, M. (2010). The 5-Minute Clinical Consult 2010
(25th ed.). Print (The 5-Minute Consult Series).
Th Midterm Exam: Attempt review (page 29 of 50)
@ https://mri.mrooms.net/mod/quiz/review.php?attempt=454700&cmid=405198&page=28
AMRU Home
Advanced Practice in Primary Care
Question 29
Complete
Mark 1.00 out of
1.00
Patrick is 32 years-old Caucasian male patient that presents to the clinic with fever (101.3 degree Fahrenheit), persistent cough, yellow-
greenish sputum production, and headaches that started about 3 days ago. He received the flu shot last month and denies any allergies or
recent travel out of the state or the country. Positive findings on physical examination include resonance to percussion of the lungs and
scattered rhonchi that clear with coughing. Based on the case scenario, what is your presumptive diagnosis?
P Flag question
Select one:
a. Chronic bronchitis
b. Acute fungal bronchitis
C. Acute viral bronchitis
d. Acute bacterial bronchitis
– Previous page
Next page
MRU Home
dvanced Practice in Primary Care
Question 11
Complete
Mark 1.00 out of
1.00
P Flag question
A 55 years-old male patient presents to the Acute Care Clinic with complaints of low-grade intermittent fever since 2 days ago
accompanied by dyspnea and retrosternal chest pain that radiates to the trapezius ridge and neck. The pain is pleuritic in quality, worsens
during inspiration and when lying flat. He reports some relief by leaning forward while seated. He The 12-lead ECG appears below. What is
the most likely diagnosis?
from wwwt
regen tunn
??,???-??-??-?-?-?
_?_?????
M_M_?_?
ME
gregar
mu
??????
Select one:
a. Acute anterior wall myocardial infarction
b. Acute lateral wall myocardial infarction
c. Acute inferior wall myocardial infarction
d. Acute pericarditis
3
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