Publication Manual of the American Psychological Association Essay

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Publication Manual of the American Psychological Association Essay

Typing Template for SOAP notes: A Sample for NU664B and NU665B

Assessment

This is the differential diagnosis section. List FOUR differential / working diagnoses. One of these will be your final diagnosis. For EACH of your diagnoses, list a brief rationale indicating why this diagnosis should be considered or not considered as the final diagnosis. Include references used to guide your thinking.

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  4. Publication Manual of the American Psychological Association Essay

Final Diagnosis:

Plan

All plans until you graduate contain the following elements. If an item does not apply to the particular situation, please indicate not applicable or not needed at this time. If it’s not indicated, it is assumed to not have been addressed.

Pharmacology

Medications—both prescription and OTC—go here. Write out your prescription meds just like a prescription.

Non-Pharmacology

What non-pharmacologic interventions do you recommend for your patient?

Diagnostics

Are there any lab tests, radiology, or other diagnostics you would like to order? Remember to think primary care. No troponins or bedside stat echos in the office.

Consults/Referrals

Would you like to phone a friend? Should they follow up with a specialist for additional or further care?

Patient Education

What important information do you need to make certain they know? Don’t forget about serious medication interactions or OCP.

Follow Up

Think about how much leeway you want to give this patient before someone lays eyes on them again? One week? Two? What should they do if they experience new or worsening symptoms? Publication Manual of the American Psychological Association Essay

Sample Plan

Here is how this needs to look on i-Human submissions: (This is a sample only—do not include in your submission.)

Pharmacology:
  • Ramipril 10mg 1 tablet PO QD
  • Norvasc 5mg 1 tablet PO QHS
  • HCTZ 12.5mg 1 tablet PO QAM
  • (more if needed)
Non-pharmacology
  • DASH diet
  • Lifestyle modifications: exercise, etc.
  • Avoid caffeine and other stimulants
  • (more if needed)
Labs
  • CBC (anemia, “paleness,” fatigue)
  • CMP (liver function, renal function, electrolytes, nutrition status)
  • BNP (cardiac dysfunction)
  • Microalbumin (kidney function—due annually for htn/dm patients)
  • (more if needed)
Diagnostics
  • EKG
  • ECHO
  • Stress test
  • Sleep study
  • (more if needed)
Patient education
  • Compression stockings may help with the edema as will reducing the calcium channel blocker. You need to check your blood pressure twice a day before you take your medications and keep a log. Please bring this log to your appointments.
  • Address the benefits and limitations to each medication. Address common side effects and the patient goals. Also, address common education topics.
  • (more if needed) Publication Manual of the American Psychological Association Essay
Referrals
  • Cardiology
  • (more if needed)
Follow up
  • Follow-up appointment in 1 week to address medication changes and review additional laboratory results (CITATIONsA, 2020; CITATIONsB, 2020)

 

References

American Psychological Association. (2020). Publication Manual of the American Psychological Association (7th ed.). American Psychological Association.

Daresh, J. C. (2004). Beginning the assistant principalship: A practical guide for new school administrators. Corwin.

Herbst-Damm, K. L., & Kulik, J. A. (2005). Volunteer support, marital status, and the survival times of terminally ill patients. Health Psychology, 24, 225–229. doi:10.1037/0278-6133.24.2.225

U.S. Department of Health and Human Services, National Institutes of Health, National Heart, Lung, and Blood Institute. (2003). Managing asthma: A guide for schools (NIH Publication No. 02-2650). 

Assessment:

DDX:

  1. Exanthema Subitum

This is also known as Roseola infantum. According to Mullins et al.,2022, Exanthema subitem is a viral disease caused by human herpesvirus and affects children of 6 to 12 months. Clinical presentations include fever of 104F lasting about 3 days, irritability, cough and upper respiratory tract symptoms, erythematous papula, non-pruritic rash occurring about three days after the onset of fever. The rash begins on the trunk, then spreads to the neck, extremities and face. Harper presents with all of the above presentation and this makes it the most probable diagnosis. Publication Manual of the American Psychological Association Essay

  1. Rubella

Rubella is a mild viral disease caused by genus Rubi virus. It is mostly asymptomatic in young children, affects children 5-9 years of age, incubation is 2-3 weeks. It presents with sore throat, low grade fever, anorexia, lymphadenopathy, pin point oink rash that begins on the face and spreads to the trunk and extremities (Leonor et al., 2022). In Harper’s case, the rash begins on the trunk spreading to the extremities, fever is high grade and has no lymphadenopathy. This rules Rubella from being the most probable diagnosis.

  1. Measles

Measles is also a viral infection caused by paramyxoviridae, presents with fever, generalized rash, cough, conjunctivitis and coryza (Kondamundi et al.,2023)

In our case, patient has localized rash, lacks conjunctivitis and coryza.

 

 

  1. Viral upper respiratory infection (URI)

This is a swelling of the upper airway involving the nose, pharynx, sinuses, large airway and larynx. It’s mainly caused by Rhinovirus. Patient presents with cough, runny nose, headache, sore throat, sneezing, malaise, myalgias and low-grade fever (Thomas et al.,2018)

In our case, patient present with cough, runny nose and fever and lacks other symptoms hence less likely to be the diagnosis.

 

  1. Human Parnovirus

This is a viral infection in a family of Parvoviridae. Patient presents with fever, chills, headache, myalgia, itching, rash and arthralgia (Heegard et al.,2022). Patient lacks itchiness, myalgia, headache and arthralgia and hence less likely to be a diagnosis. Publication Manual of the American Psychological Association Essay

Final Diagnosis:

  1. Exanthema Subitum

 

Plan

Pharmacology

Acetaminophen 250 mg PO tid to control fever.

 

Non-Pharmacology

Mother is advised to ensure the baby gets enough rest.

To handwash frequently and thoroughly.

To take a lot of fluids.

Diagnostics

No lab or diagnostic tests are required in this case.

Consults/Referrals

No referral is needed in this case.

Patient Education

Mother is educated on the child’s diagnosis.

Mother is reassured the disease is self-limiting and no actual treatment.

Mother is made aware full recovery will take a week or so.

The medication prescribed is for fever only.

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Follow Up

Patient should be brought immediately if fever persists.

She should come back if rash worsens.

Come back after a week for follow-up

 

 

 

References

Heegaard, E. D., & Brown, K. E. (2022). Human parvovirus B19. Clinical microbiology reviews, 15(3), 485-505.

Kondamudi NP, Waymack JR. Measles. [Updated 2022 Dec 23]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2023 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK448068/

Leonor, M. C., & Mendez, M. D. (2022). Rubella. In StatPearls [Internet]. StatPearls Publishing.

Mullins, T. B., & Krishnamurthy, K. (2022). Roseola infantum. In StatPearls [Internet]. StatPearls Publishing.

Thomas, M., & Bomar, P. A. (2018). Upper respiratory tract infection. Publication Manual of the American Psychological Association Essay