Clinical Reasoning and the Physical Assessment Paper

Clinical Reasoning and the Physical Assessment Paper

For this assignment, you will utilize course materials, textbooks, and the provided SOAP Note Format document to conduct a comprehensive history assessment on a chosen individual—an acquaintance, colleague, or family member—portraying a patient seeking a history and physical examination. This scenario mirrors the type of history collection you might undertake with a new patient or during an annual wellness checkup. Craft a chief complaint to facilitate documentation of the OLDCART (HPI) data.

Clinical Reasoning and Physical Assessment: Subjective Patient History

Myths About Seeing a Nurse Practitioner vs. a Doctor

The chief complaint should encompass fatigue, fever, and muscle aches. Your documentation should encompass a comprehensive ROS and all other elements of a full patient history. This week, your focus will be on recording the subjective section of the SOAP note, omitting the objective section. Organize your findings in a systematic manner and pinpoint key history components that could indicate primary care interventions necessary for this patient. Share these observations within this discussion.