For this assignment, you are to complete a clinical case - narrated PowerPoint report that will follow the SOAP note example provided below. The case report will be based on the clinical case scenario list below.   You are to approach this clinical scenario as if it is a real patient in the clinical setting. Instructions: Step 1 - Read the assigned clinical scenario and using your clinical reasoning skills, decide on the diagnoses. This step informs your next steps. Step 2 - Document the given information in the case scenario under the appropriate sections, headings, and subheadings of the SOAP note. Step 3 - Document all the classic symptoms typically associated with the diagnoses in Step 1. This information may NOT be given in the scenario; you are to obtain this information from your textbooks. Include APA citations. Example of Steps 1 - 3: You decided on Angina after reading the clinical case scenario (Step 1) Review of Symptoms (list of classic symptoms): CV: sweating, squeezing, pressure, heaviness, tightening, burning across the chest starting behind the breastbone GI: indigestion, heartburn, nausea, cramping Pain: pain to the neck, jaw, arms, shoulders, throat, back, and teeth Resp: shortness of breath Musculo: weakness Step 4 – Document the abnormal physical exam findings typically associated with the acute and chronic diagnoses decided on in Step 1. Again, this information may NOT be given. Cull this information from the textbooks. Include APA citations. Example of Step 4: You determined the patient has Angina in Step 1 Physical Examination (list of classic exam findings): CV: RRR, murmur grade 1/4 Resp: diminished breath sounds left lower lobe Step 5 - Document the diagnoses in the appropriate sections, including the ICD-10 codes, from Step 1. Include three differential diagnoses. Define each diagnosis and support each differential diagnosis with pertinent positives and negatives and what makes these choices plausible. This information may come from your textbooks. Remember to cite using APA. Step 6 - Develop a treatment plan for the diagnoses. Only use National Clinical Guidelines to develop your treatment plans. This information will not come from your textbooks. Use your research skills to locate appropriate guidelines. The treatment plan must address the following: a) Medications (include the dosage in mg/kg, frequency, route, and the number of days) b) Laboratory tests ordered (include why ordered and what the results of the test may indicate) c) Diagnostic tests ordered (include why ordered and what the results of the test may indicate) d) Vaccines administered this visit & vaccine administration forms given, e) Non-pharmacological treatments f) Patient/Family education including preventive care g) Anticipatory guidance for the visit (be sure to include exactly what you discussed during the visit; review Bright Futures website for this section) h) Follow-up appointment wit.

1. For this assignment, you are to complete a
clinical case - narrated PowerPoint report
that will follow the SOAP note example provided below. The
case report will be based on the clinical case scenario list
below.
You are to approach this clinical scenario as if it is a real
patient in the clinical setting.
Instructions:
Step 1
- Read the assigned clinical scenario and using your clinical
reasoning skills, decide on the diagnoses. This step informs
your next steps.
Step 2
- Document the given information in the case scenario under the
appropriate sections, headings, and subheadings of the SOAP
note.
Step 3
- Document all the classic symptoms typically associated with
the diagnoses in Step 1. This information may NOT be given in
the scenario; you are to obtain this information from your

2. textbooks. Include APA citations.
Example of Steps 1 - 3:
You decided on Angina after reading the clinical case scenario
(Step 1)
Review of Symptoms (list of classic symptoms):
CV: sweating, squeezing, pressure, heaviness, tightening,
burning across the chest starting behind the breastbone
GI: indigestion, heartburn, nausea, cramping
Pain: pain to the neck, jaw, arms, shoulders, throat, back, and
teeth
Resp: shortness of breath
Musculo: weakness
Step 4
– Document the abnormal physical exam findings typically
associated with the acute and chronic diagnoses decided on in
Step 1. Again, this information may NOT be given. Cull this
information from the textbooks. Include APA citations.
Example of Step 4:
You determined the patient has Angina in Step 1

3. Physical Examination (list of classic exam findings):
CV: RRR, murmur grade 1/4
Resp: diminished breath sounds left lower lobe
Step 5
- Document the diagnoses in the appropriate sections, including
the ICD-10 codes, from Step 1. Include three differential
diagnoses. Define each diagnosis and support each differential
diagnosis with pertinent positives and negatives and what makes
these choices plausible. This information may come from your
textbooks. Remember to cite using APA.
Step 6
- Develop a treatment plan for the diagnoses.
Only
use National Clinical Guidelines to develop your treatment
plans. This information will not come from your textbooks. Use
your research skills to locate appropriate guidelines. The
treatment plan
must
address the following:
a) Medications (include the dosage in mg/kg, frequency, route,
and the number of days)

4. b) Laboratory tests ordered (include why ordered and what the
results of the test may indicate)
c) Diagnostic tests ordered (include why ordered and what the
results of the test may indicate)
d) Vaccines administered this visit & vaccine administration
forms given,
e) Non-pharmacological treatments
f) Patient/Family education including preventive care
g) Anticipatory guidance for the visit (be sure to include exactly
what you discussed during the visit; review Bright Futures
website for this section)
h) Follow-up appointment with a detailed plan of f/u
CLINICAL CASE SCENARIOA 7-month-old male child arrives
at your clinic for a well-child examination. His family recently
emigrated to the United States from West Africa. His medical
history is positive for abdominal pain and his family history is
positive for maternal hypertension and paternal hyperlipidemia.
The father smokes a pack a day and smokes in the home. The
child’s sole source of nutrition is goat’s milk. He appears to be
healthy on examination and his point-of-care complete blood
count shows large red blood cells. Today, his vitals are as
follows: weight 18.3 lbs, height 27.2 inches, BP 80/56, HR 100,
RR 26, and Temperature is 98.6 F.
Diagnosis – Megaloblastic Anemia

5. As you develop your narrated PowerPoint, be sure to address
the criteria discussed in the video above and the instructions
listed below:
FOLLOW THE TEMPLATE BELOW for the Clinical Case
Report - SOAP PowerPoint Assignment:
DO NOT INCLUDE THESE INSTRUCTIONS IN THE
POWERPOINT. POINTS WILL BE DEDUCTED. REFER TO
THE EXAMPLE CASE REPORT FOR GUIDANCE.
SUBJECTIVE (S): Describes what the patient reports about
their condition.
For INITIAL visits gather the info below from the clinical
scenario and the textbook. DO NOT COPY AND PASTE THE
SCENARIO; EXTRACT THE RELEVANT INFORMATION.
Historian (required; unless the patient is 16 y/o and older):
document name and relationship of guardian
Patient’s Initials + CC (Identification and Chief Complaint):
E.g. 6-year-old female here for evaluation of a palmar rash
HPI (History of Present Illness): Remember OLD CAARTS
(onset, location, duration, character, aggravating/alleviating
factors, radiation, temporal association, severity) written in
paragraph form

6. PMH (Past Medical History): List any past or present medical
conditions, surgeries, or other medical interventions the patient
has had. Specify what year they took place
MEDs: List prescription medications the patient is taking.
Include dosage and frequency if known. Inquire and document
any over-the-counter, herbal, or traditional remedies.
Allergies: List any allergies the patient has and indicate the
reaction. e.g. Medications (tetracycline-> shortness of breath),
foods, tape, iodine->rash
FH (Family History): List relevant health history of immediate
family: grandparents, parents, siblings, or children. e.g. Inquire
about any cardiovascular disease, HTN, DM, cancer, or any
lung, liver, renal disease, etc...
SHx (Social history): document parent’s work (current),
educational level, living situation (renting, homeless, owner),
substance use/abuse (alcohol, tobacco, marijuana, illicit drugs),
firearms in-home, relationship status (married, single, divorced,
widowed), number of children in the home (in SF or abroad),
how recently pt immigrated to the US and from what country of
origin (if applicable), the gender of sexual partners, # of
partners in last 6 mo, vaginal/anal/oral, protected/unprotected.
Patient Profile: Activities of Daily Living (age-appropriate):
(include feeding, sleeping, bathing, dressing, chores, etc.),
Changes in daycare/school/after-school care, Sports/physical
activity, and Developmental History: (provide a history of
development over the child’s lifespan. If a child is 1y/o or
younger, provide birth history also)
HRB (Health-related behaviors):

7. ROS (Review of Systems): Asking about problems by organ
system systematically from head-to-toe. Included classic
associated symptoms (this includes pertinent negatives and
positives).
OBJECTIVE: Physical findings you observe or find on the
exam.
1. Age, gender, general appearance
2. Vitals – HR, BP, RR, Temp, BMI, Height & Percentile;
Weight & Percentile, Include the Growth Chart
3. Physical Exam: note pertinent positives and negatives (refer
to the textbook for classic findings related to present complaint
and the diagnosis you believe the patient has)
4. Lab Section – what results do you have?
5. Studies/Radiology/Pap Results Section – what results do you
have?
RISK FACTORS: List risk factors for the acute and chronic
conditions
ASSESSMENT: What do you think is going on based on the
clinical case scenario? This is based on the case. You are to list
the acute diagnosis and three differential diagnoses, in order of
what is likely, possible, and unlikely (include supporting
information that helped you to arrive at these differentials). You
must include the ICD-10 codes, the definition for the acute and

8. differential diagnoses, and the pertinent positives and negatives
of each diagnosis.
You are to also list any chronic conditions with the ICD-10
codes.
NATIONAL CLINICAL GUIDELINES: List the guidelines you
will use to guide your treatment and management plan
TREATMENT & MANAGEMENT PLAN: Number problems
(E.g. 1. HTN, 2. DM, 3. Knee sprain), use bullet points, and
include A – F below for each diagnosis and G – H after you’ve
addressed all conditions.
Example:
1. HTN
a) Vaccines administered this visit & vaccine administration
forms given,
b) Medication-include dosage amounts and mg/kg for drug and
number of days,
c) Laboratory tests ordered
d) Diagnostic tests ordered
e) Non-pharmaceutical treatments

9. f) Patient/Family education including preventive care
2. HLD
a) Vaccines administered this visit & vaccine administration
forms given,
b) Medication-include dosage amounts and mg/kg for drug and
number of days,
c) Laboratory tests ordered
d) Diagnostic tests ordered
e) Non-pharmaceutical treatments
f) Patient/Family education including preventive care
Also discussed:
g) Anticipatory guidance for next well-child visit (be sure to
include exactly what you discussed during the visit; review
Bright Futures website for this section)

10. Return to the clinic:
h) Follow-up appointment with a detailed plan for f/u and any
referrals
Submission Details:
Post the Week 2 Clinical Case Report SOAP Note Assignment
to the
Discussion Board
below
by the date assigned.
Name your Case Report SOAP note document
NSG6435_W2_SOAP_LastName_FirstInitial.ppt.
Below is an Example Clinical Case Report - Remember yours
must be narrated PowerPoint: