Clinical case presentation should be in a SOAP format. Same SOAP format you use to submit your notes on Typhon. But you must make sure the information provided bellow is included or added for the purpose of this paper.
It should be written in correct gramma, no APA but the references.
References must be on APA format at the end of your papers corresponding to the citations throughout your paper.
An unusual case means a challenging case to you.
From the soap you will use:
- Chief complain and history of present disease
- Exam and diagnostic tests ( labs , images)
- Dx impression supported by signs and symptoms
- Management as on soap I sent : meds, tests if any ordered, education, follow up
- Evidence based rationale for treatment. Like aspirin is an antiplatelet use to … and it’s reference
- Epidemiological data with reference. For example angina. Go to the CDC website and look for percent of populations affected, distribution with USA population.
- Analysis of self care and family issues r/t diagnosis and tx plan related to your Dx. Ex. Patient is poor compliant with medication and no family support. First choice of antianginal tx not use because lack of insurance coverage and use —-instead
- Evaluate parameters to determine outcome. Use same as the shorts and long term goals on our RN care plans but more treatment and prevention related.
- Major lesson learned from the case and how may affect your future practice. This analysis is your experience.
Attached it is the Soap Note template
and information that can be use to do the soap note