4457 – My Nursing Assignment
Student must complete a sopa note using the template
Each diagnosis and differential diagnosis MUST BE SUPPORTTED BY OBJECTIVE AND SUBJECTIVE S/S with REFERENCE ( minimum 3 reference x soap note)
Patient :68 years old, hispanic male
CC:
“Patient reports that he had rash in his arm, bloody diarrhea and abdominal pain for the last 2 days without relief.”
Diagnosis:
Hemolytic Uremic Syndrome (ICD 10: D59.3).
Differencial Diagnosis:
Gastroenteritis
Irritable bowel syndrome (IBS)
Necrotizing enterocolitis
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