What details did the patient provide regarding or her personal and medical history?
With this patient in mind, address the following in a SOAP Note:
Subjective: What details did the patient provide regarding or her personal and medical history?
Objective: What observations did you make during the physical assessment?
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Order Paper NowAssessment: What were your differential diagnoses? Provide a minimum of three possible diagnoses. List them from highest priority to lowest priority. What was your primary diagnosis and why?
Plan: What was your plan for diagnostics and primary diagnosis? What was your plan for treatment and management, including alternative therapies? Include pharmacologic and nonpharmacologic treatments, alternative therapies, and follow-up parameters, as well as a rationale for this treatment and management plan.
Reflection notes: What would you do differently in a similar patient evaluation?
