SOAP note – Reported unprotected sex – HA w11 DT1
Type of document Essay
1 Page Double Spaced
Subject area Nursing
Academic Level Ph. D.
Style APA
References 3
Order description:
Discussion Prompt:
Given the following scenario, you will note an incomplete assessment.
Based on the information you have, make an impression of what you think is the client’s problem(s). For example, you may think that the client is in heart failure.
Ask yourself what additional subjective and objective data you will need to confirm that diagnosis. Include this information in the scenario. For example, give a lab results that will be indicative of heart failure.
What are the possible differential diagnoses for this client?
Defend your diagnosis or diagnoses with documentation from required readings, pathophysiology book; nurse practitioner’s protocols found in books and journals, and professional journal articles.
Give a rationale for your contribution to the management plan.
At the end of the SOAP note, insert the references you used into a master reference list using the APA format (this will enable your classmate to use your references for further study or research).
Every student should make at least two comments in developing data for the diagnoses.
Every student should make at least one comment on two students’ comments. Indicate whether you agree or disagree; give justification and documentation for your comments.
Every student must contribute to the management plan. Focus the plan on non-medication treatments, the diagnostic plan, and your teaching plan. Each student will contribute at least two comments to the plan.
Scenario
A 56-year-old male who returns from a wild weekend in Las Vegas. He is complaining of a white milky discharge from his penis. Reported unprotected sex with a woman he met in Las Vegas. The discharged started 4 days ago and he is experiencing pain with urination. PMHx: HTN and Inguinal hernia. Meds: HCTZ. Allergies: NKDA. Social Hx: nonsmoker, nondrinker, travels extensively and has never had this problem before.
** ALL REFERENCES MUST BE IN APA FORMAT AND WITHIN THE LAST 5 YEARS OF PUBLICATION.
