Clinical Reasoning and the Physical Assessment
Using course materials, textbooks, and the SOAP Note Format document provided in the Course Resources area of the course, choose a friend, colleague, or family member and perform a complete history on your “patient” that presents for a history and physical examination. This is the kind of history you might obtain from a new patient, or during an annual well-visit exam. You should devise a chief complaint so that you may document the OLDCART (HPI) data. You must use the chief complaint of fatigue, fever, and muscles aches.
You should include a complete ROS and all the other components of a complete patient history. This week you will only need to document the subjective portion of the SOAP note (not objective). Document your findings in a systematic manner and identify some of the key components of the history that may tip you off to primary care interventions that this patient may require. Share these findings in this discussion.
