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Academic clinical SOAP notes provide a unique opportunity to practice and demonstrate advanced practice documentation skills, to develop and demonstrate critical thinking and clinical reasoning skills, and to practice identifying acute and chronic problems and formulating evidence-based plans of care. Develop a hospital follow-up progress SOAP note based on a clinical patient from your practicum setting. In your assessment, provide the following: · A one-sentence description of the primary working diagnosis, pending differential diagnoses, and the context or service in which the patient is being seen.( Acute Care Hospital) · A one-to-two paragraph description of the current illness or hospital stay, including pertinent diagnostic findings or procedures. Include how many days the patient has been hospitalized, if applicable. · List of at least five systems affected by the working diagnosis. Provide two positive or negative effects that the working diagnosis has on each system. · List of at least five systems examined within the last 24 hours. Provide at least two pertinent positive or negative findings relevant to each system examined and include a full set of vital signs. · List of all admission diagnostics conducted for this visit or conducted within the last 24 hours.( (CPT codes) · List of all pertinent acute and chronic diagnoses in order of priority using ICD-10. Identify any differential diagnoses being eliminated. · Treatment plan that corresponds with the diagnosis. Provide information on admission type, types of diagnostics, any prescribed medications and dosages, and any relevant consults or follow-up procedures needed. · Discussion of any relevant ethical, legal, or geriatric-specific considerations. Incorporate at least 3-5 peer-reviewed articles in the assessment or plan. (Minimum 1200 words). Don’t Forget to include all coding including ICD-10, CPT and all others. While APA style is not required for the body of this assignment, solid academic writing is expected, and documentation of sources should be presented using APA formatting guidelines, which can be found in the APA Style Guide, located in the Student Success Center. This assignment uses a rubric. Please review the rubric prior to beginning the assignment to become familiar with the expectations for successful completion. You are required to submit this assignment to LopesWrite. Refer to the LopesWrite Technical Support articles for assistance.1 2 Academic Clinical SOAP Note Muhammad Aftkhar Grand Canyon University January 25th, 2021 Academic Clinical SOAP Note Subjective Chief complaint A 62 years old male was brought to the ED by his wife with a three-day history of short breathing, wheezing, grunting, nose flaring, productive cough, and gradual change in the color of sputum from yellow to brown (Fermont et al., 2020). Primary working diagnosis · COPD acute exacerbation (J44.1) Acute exacerbation of chronic obstructive pulmonary disease manifests a sudden worsening of coughing symptoms, wheezing, fatigue, color, quantity, and sputum consistency. These symptoms typically last for several days and cause extreme discomfort to the patient. Pending differential diagnosis · Asthma (J 45.901) · Congestive heart failure (150.20) · Pneumothorax (J 93.9) · Pleural effusion (J 90) · Pulmonary embolism (126.99) · Cardiac arrhythmia (149.9) History of present illness The patient has been experiencing short breathing for the last two years, and it has been getting worse for the past four days. The patient is positive for dyspnea on exertion. The patient has reported fever, chills, night sweats, chest pain, and palpitation. Moreover, the patient has signs of lower extremity edema. However, the patient was rather uncomfortable because of labored breathing. He has been using different kinds of inhalers, yet he has not completely recovered from the cough. He has been hospitalized multiple times for acute COPD exacerbations. The diagnosis is made based on present medical history, breathing profile, and spirometry results. FEV1/FVC ratio was 0.68 (68\%). The ABG test indicated that the oxygen saturation is not satisfactory, the values are, PaO2 = 58, PaCO2 = 30, Arterial blood PH = 7.32, SaO2 = 86. The patient has a long history of smoking, and he is a chain smoker. He is not an alcoholic and does not use any illicit drugs. He needs urgent hospitalization for oxygen therapy. Past medical history · Hypertension (I10) · Emphysema (J 43.9) Past surgeries · Hernia repair surgery (K 46.9) · 2-day hospitalization · Multiple hospitalizations for COPD Family history · Mother died of heart failure · Father had COPD · Brother has hypertension · Sister is normal Medication · Lisinopril 20 mg BD · Atorvastatin 20 mg BD · Salmeterol 250/50 inhaler, two puffs daily · Albuterol nebulizer every 8 hours daily Hypertension · Lotensin 40 mg OD · Zestril 20 mg OD Emphysema · Duakril inhaler two puffs daily Review of systems Constitutional symptoms Fatigue, 20 LB weight loss. Slight weakness, no fever, no night sweats. The patient seemed fatigued, and he stated that he lost 20 LB weight during the last six months. However, the patient had no fever, and no sweating was observed. Eyes No obvious visual changes. The color of the sclera was normal. Upon investigation, the patient said that he did not feel any visual problem. The diagnosis has no negative effect on ocRubic_Print_Format Course Code Class Code Assignment Title Total Points ANP-650 ANP-650-XO0103XB Academic Clinical SOAP Note 65.0 Criteria Percentage Excellent (100.00\%) Content 70.0\% Primary or Working Diagnosis 10.0\% A one-sentence description of the primary working diagnosis, pending differential diagnoses, and context or service in which the patient is being seen is provided and includes supporting details. Brief Clinical Course 10.0\% A one-to-two paragraph description of the current illness or hospital stay, including pertinent diagnostic findings or procedures and the number of days since the patient has been hospitalized, is complete with supporting documentation. Review Of Systems 10.0\% Five systems affected by the working diagnosis, along with two positive or negative effects of the diagnosis on each system, are provided with thorough details and support. Exam 10.0\% Five systems examined within the last 24 hours, including two positive or negative findings relevant to each system and a full set of vital signs, are provided with thorough details and support. Diagnostics 10.0\% Admission diagnostics are provided with thorough details and support. Impression or Assessment 10.0\% Identification of all acute and chronic diagnoses in order of ICD-10 priority and any differential diagnoses being eliminated are provided with thorough details and support. Plan 5.0\% A treatment plan that corresponds with the diagnosis and includes admission type, diagnostics, medications and dosages, and any consults or follow-up procedures needed is provided with thorough details and support. Geriatric Specific Care 5.0\% A discussion of ethical, legal, or geriatric considerations is provided with thorough details and support. Organization and Effectiveness 10.0\% Mechanics of Writing (includes spelling, punctuation, grammar, language use) 10.0\% Writer is clearly in command of standard, written, academic English. Format 20.0\% Paper Format (Use of appropriate style for the major and assignment) 10.0\% All format elements are correct. Documentation of Sources (citations, footnotes, references, bibliography, etc., as appropriate to assignment and style) 10.0\% Sources are completely and correctly documented, as appropriate to assignment and style, and format is free of error. Total Weightage 100\%1 2 Academic Clinical SOAP Note Academic Clinical SOAP Note Subjective Chief complaint A 62 years old male was brought to the ED by his wife with a three-day history of short breathing, wheezing, grunting, nose flaring, productive cough, and gradual change in the color of sputum from yellow to brown (Fermont et al., 2020). Primary working diagnosis · COPD acute exacerbation (J44.1) Acute exacerbation of chronic obstructive pulmonary disease manifests a sudden worsening of coughing symptoms, wheezing, fatigue, color, quantity, and sputum consistency. These symptoms typically last for several days and cause extreme discomfort to the patient. Pending differential diagnosis · Asthma (J 45.901) · Congestive heart failure (150.20) · Pneumothorax (J 93.9) · Pleural effusion (J 90) · Pulmonary embolism (126.99) · Cardiac arrhythmia (149.9) History of present illness The patient has been experiencing short breathing for the last two years, and it has been getting worse for the past four days. The patient is positive for dyspnea on exertion. The patient has reported fever, chills, night sweats, chest pain, and palpitation. Moreover, the patient has signs of lower extremity edema. However, the patient was rather uncomfortable because of labored breathing. He has been using different kinds of inhalers, yet he has not completely recovered from the cough. He has been hospitalized multiple times for acute COPD exacerbations. The diagnosis is made based on present medical history, breathing profile, and spirometry results. FEV1/FVC ratio was 0.68 (68\%). The ABG test indicated that the oxygen saturation is not satisfactory, the values are, PaO2 = 58, PaCO2 = 30, Arterial blood PH = 7.32, SaO2 = 86. The patient has a long history of smoking, and he is a chain smoker. He is not an alcoholic and does not use any illicit drugs. He needs urgent hospitalization for oxygen therapy. Past medical history · Hypertension (I10) · Emphysema (J 43.9) Past surgeries · Hernia repair surgery (K 46.9) · 2-day hospitalization · Multiple hospitalizations for COPD Family history · Mother died of heart failure · Father had COPD · Brother has hypertension · Sister is normal Medication · Lisinopril 20 mg BD · Atorvastatin 20 mg BD · Salmeterol 250/50 inhaler, two puffs daily · Albuterol nebulizer every 8 hours daily Hypertension · Lotensin 40 mg OD · Zestril 20 mg OD Emphysema · Duakril inhaler two puffs daily Review of systems Constitutional symptoms Fatigue, 20 LB weight loss. Slight weakness, no fever, no night sweats. The patient seemed fatigued, and he stated that he lost 20 LB weight during the last six months. However, the patient had no fever, and no sweating was observed. Eyes No obvious visual changes. The color of the sclera was normal. Upon investigation, the patient said that he did not feel any visual problem. The diagnosis has no negative effect on ocular microvasculature. Retinal oxygen level is normal. ENT