{"id":11319,"date":"2024-02-12T09:19:40","date_gmt":"2024-02-12T09:19:40","guid":{"rendered":"https:\/\/www.writemyessays.app\/blog\/questions\/comprehensive-diagnosis-treatment-plan-cdtp-soap-for-5yo-female-with-allergic-rhinitis-acute-nasopharyngitis\/"},"modified":"2024-02-12T09:19:40","modified_gmt":"2024-02-12T09:19:40","slug":"comprehensive-diagnosis-treatment-plan-cdtp-soap-for-5yo-female-with-allergic-rhinitis-acute-nasopharyngitis","status":"publish","type":"questions","link":"https:\/\/www.writemyessays.app\/blog\/questions\/comprehensive-diagnosis-treatment-plan-cdtp-soap-for-5yo-female-with-allergic-rhinitis-acute-nasopharyngitis\/","title":{"rendered":"Comprehensive Diagnosis & Treatment Plan (CDTP) (SOAP) For 5yo Female with Allergic rhinitis, Acute Nasopharyngitis"},"content":{"rendered":"

 Comprehensive Diagnosis & Treatment Plan (CDTP) (SOAP) For 5yo Female with Allergic rhinitis, Acute Nasopharyngitis<\/u><\/b><\/p>\n


<\/u><\/b><\/div>\n
USE ATTACHED CDTP TEMPLATE TO INSERT INFORMATION
<\/u><\/b><\/p>\n
<\/div>\n
\n

<\/p>\n

Directions: Label each section of the Comprehensive Diagnosis & Treatment Plan<\/p>\n

(CDTP) (SOAP), each body part and system. Do not use unnecessary words or<\/p>\n

complete sentences. Use only approved medical abbreviations (S=subjective;<\/p>\n

CC=chief complaint; etc). See topic outline for the 5 assigned populations.<\/p>\n

Title: Student name, CDTP #1-5, population: Example: J. Smith, CDTP #1, Peds<\/p>\n

S: Subjective Data<\/p>\n

CC: A statement describing the symptom, problem, condition, diagnosis, or other reason for<\/p>\n

visit. Use quotes (pts own words) in this section.<\/p>\n

HPI: (History of present illness) A chronological description of the development of the<\/p>\n

patient’s present illness from the first sign or symptom or from the previous encounter to<\/p>\n

the present. Symptom analysis 7 Variables: location, quality, severity, duration, timing,<\/p>\n

modifying factors, associated signs and symptoms. Or an update on health status from<\/p>\n

the past year or last visit.<\/p>\n

PMH: Update current medications, allergies, prior child and adult illnesses and injuries,<\/p>\n

operations and hospitalizations allergies, age-appropriate immunization status. LMP.<\/p>\n

PSH (Surgical History) list dates and surgeries and reasons for surgery if significant<\/p>\n

(cancer).<\/p>\n

FH: (Family History) Update significant medical information about the patient’s family<\/p>\n

(parents, siblings, and children). Include specific diseases related to problems identified<\/p>\n

in CC, HPI or ROS.<\/p>\n

SH: (Social History) An age-appropriate review of significant activities that may include<\/p>\n

information such as marital status, living arrangements, occupation or grade in school,<\/p>\n

history of use of drugs, alcohol or tobacco, extent of education and sexual history.<\/p>\n

ROS: (Review of Systems). There are 14 systems for review. List positive findings and<\/p>\n

pertinent negatives in systems directly related to the systems identified in the CC and<\/p>\n

symptoms which have occurred since last visit; (1) constitutional symptoms (e.g., fever,<\/p>\n

weight loss), (2) eyes, (3) ears, nose, mouth and throat, (4) cardiovascular, (5)<\/p>\n

respiratory, (6) gastrointestinal, (7) genitourinary, (8) musculoskeletal, (9) integumentary<\/p>\n

(skin and\/or breast), (10) neurologic, (11) psychiatric, (12) endocrine, (13)<\/p>\n

hematologic\/lymphatic, {14) allergic\/immunologic and no need to repeat information if<\/p>\n

provided in the HPI.<\/p>\n

0: Objective Data.<\/p>\n

Vital signs: BP; HR; RR; Ht; Wt; BMI, pain, LMP. Head, chest, length if appropriate. Age or<\/p>\n

population specific findings. Sufficient physical exam should be performed to evaluate areas<\/p>\n

suggested by the history and patient’s progress since last visit. Document specific abnormal and<\/p>\n

relevant negative findings. Abnormal or unexpected findings should be described. “Negative” or<\/p>\n

“Normal” findings should be noted if related to body areas or findings not relevant to the<\/p>\n

patient’s problem. Don\u2019t use \u201cnormal\u201d; \u201cWNL\u201d or \u201cexpected findings\u201d be descriptive with your<\/p>\n

physical findings. Record observations for the following systems (there are 12 systems for<\/p>\n

examination), if they were examined: Constitutional (e.g. VS, general appearance), Eyes,<\/p>\n

ENT\/mouth, Cardiovascular, Respiratory, GI, GU, Musculoskeletal, Skin, Neurologic,<\/p>\n

Psychiatric, Hematologic\/lymphatic\/immunologic. Always document CV & Resp findings.<\/p>\n

(CV: S1S2 without murmur, rub, gallop. Resp: BBS without adventitious sounds; = chest<\/p>\n

expansion;<\/p>\n

A: Assessment and Diagnosis<\/p>\n

List and number the diagnoses (problems) in the following areas if applicable:<\/p>\n

1. Health maintenance, 2. Acute self-limiting problems, 3. Chronic health problems<\/p>\n

List Diagnoses (use medical terminology) & document ICD-9 code and a minimum<\/p>\n

of 3<\/p>\n

Differential Diagnoses for each diagnosis listed. 1. Chronic Sinusitis (473) DD: URI;<\/p>\n

Pharyngitis; Allergic Rhinitis<\/p>\n

P: Plan<\/p>\n

List actions planned to manage each problem. Number the actions to correlate with the<\/p>\n

problems in the assessment. Include diagnostic, therapeutic, and patient education actions.<\/p>\n

Anticipatory Guidance, health promotion, disease prevention for the patient, family and<\/p>\n

caregiver.<\/p>\n

Follow-up should be specified with time or circumstances of return as PRN.<\/p>\n

Prescriptions: provide all details for the order. EX: Amoxil 500 mg three time a day for 10<\/p>\n

days Disp thirty (30), no refills. Include education: take with food, take all of medication even<\/p>\n

though you may feel better, stop medicine & notify office if rash, SOB, N,V, diarrhea<\/p>\n

occurs. Be specific about the education provided, not simply \u201cexplained medication\u201d. <\/p>\n


<\/u><\/b><\/p>\n

Provide APA 7th edition <\/u><\/b>references for your assessment and plan. Do not use references older than 5 years.<\/u><\/b><\/p>\n<\/div>\n<\/div>\n","protected":false},"excerpt":{"rendered":"

 Comprehensive Diagnosis & Treatment Plan (CDTP) (SOAP) For 5yo Female with Allergic rhinitis, Acute Nasopharyngitis USE ATTACHED CDTP TEMPLATE TO INSERT INFORMATION Directions: Label each section of the Comprehensive Diagnosis & Treatment Plan (CDTP) (SOAP), each body part and system. Do not use unnecessary words or complete sentences. Use only approved medical abbreviations (S=subjective; CC=chief […]<\/p>\n","protected":false},"author":2,"featured_media":0,"comment_status":"open","ping_status":"closed","template":"","meta":[],"disciplines":[13],"paper_types":[],"tagged":[],"aioseo_notices":[],"_links":{"self":[{"href":"https:\/\/www.writemyessays.app\/blog\/wp-json\/wp\/v2\/questions\/11319"}],"collection":[{"href":"https:\/\/www.writemyessays.app\/blog\/wp-json\/wp\/v2\/questions"}],"about":[{"href":"https:\/\/www.writemyessays.app\/blog\/wp-json\/wp\/v2\/types\/questions"}],"author":[{"embeddable":true,"href":"https:\/\/www.writemyessays.app\/blog\/wp-json\/wp\/v2\/users\/2"}],"replies":[{"embeddable":true,"href":"https:\/\/www.writemyessays.app\/blog\/wp-json\/wp\/v2\/comments?post=11319"}],"version-history":[{"count":0,"href":"https:\/\/www.writemyessays.app\/blog\/wp-json\/wp\/v2\/questions\/11319\/revisions"}],"wp:attachment":[{"href":"https:\/\/www.writemyessays.app\/blog\/wp-json\/wp\/v2\/media?parent=11319"}],"wp:term":[{"taxonomy":"disciplines","embeddable":true,"href":"https:\/\/www.writemyessays.app\/blog\/wp-json\/wp\/v2\/disciplines?post=11319"},{"taxonomy":"paper_types","embeddable":true,"href":"https:\/\/www.writemyessays.app\/blog\/wp-json\/wp\/v2\/paper_types?post=11319"},{"taxonomy":"tagged","embeddable":true,"href":"https:\/\/www.writemyessays.app\/blog\/wp-json\/wp\/v2\/tagged?post=11319"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}