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El. knyga: SOAP for the Rotations

4.50/5 (2 ratings by Goodreads)
  • Formatas: 512 pages
  • Išleidimo metai: 11-Jul-2019
  • Leidėjas: Wolters Kluwer Health
  • Kalba: eng
  • ISBN-13: 9781975107666
Kitos knygos pagal šią temą:
SOAP for the RotationsDidesnis paveikslėlis
  • Formatas: 512 pages
  • Išleidimo metai: 11-Jul-2019
  • Leidėjas: Wolters Kluwer Health
  • Kalba: eng
  • ISBN-13: 9781975107666
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Ideal for medical students, PAs and NPs, this pocket-sized quick reference helps students hone the clinical reasoning and documentation skills needed for effective practice in internal medicine, pediatrics, OB/GYN, surgery, emergency medicine, and psychiatry. This updated edition offers step-by-step guidance on how to properly document patient care as it addresses the most common clinical problems encountered on the wards and clinics. Emphasizing the patient’s clinical problem, not the diagnosis, the book’s at-a-glance, two-page layout uses the familiar SOAP note format.
 
  • NEW! An expanded “How to Write a Soap Note” introduction provides templates, tips, and guidelines for writing soap notes.
  • UNIQUE: No other resource teaches clinical information and documentation through the use of a SOAP (Subjective, Objective, Assessment, Physical Exam) format.
  • PORTABLE: The book is small, portable, and easily fits into a lab coat pocket—perfect for taking along on rounds.
  • EASY-TO-ACCESS: At-a-glance, two-page layouts provide practical information using the familiar SOAP note format.
  • FOCUSED: Clear, well-written sample SOAP notes for a wide range of diagnoses emphasize the most important information needed for success on rounds.
  • ACCURATE: The SOAP approach helps students figure out where to start, while improving communication between physicians and ensuring accurate documentation.


Ideal for medical students, PAs and NPs, this pocket-sized quick reference helps students hone the clinical reasoning and documentation skills needed for effective practice in internal medicine, pediatrics, OB/GYN, surgery, emergency medicine, and psychiatry. This updated edition offers step-by-step guidance on how to properly document patient care as it addresses the most common clinical problems encountered on the wards and clinics. Emphasizing the patient’s clinical problem, not the diagnosis, the book’s at-a-glance, two-page layout uses the familiar SOAP note format.
Acknowledgments xiii
Contributors xiv
To the Reader xv
Abbreviations xvi
Normal Lab Values xxvi
How to Write a SOAP Note xxx
SECTION 1 INTERNAL MEDICINE
1(128)
Chapter 1 Pulmonary
2(10)
1 Community-Acquired Pneumonia
2(2)
2 Asthma
4(2)
3 Tuberculosis
6(2)
4 Interstitial Lung Disease
8(2)
5 Solitary Pulmonary Nodule
10(2)
Chapter 2 Cardiology
12(18)
6 Hypertension
12(2)
7 Chest Pain Evaluation
14(2)
8 Stable Angina
16(2)
9 Congestive Heart Failure
18(2)
10 Systolic Murmur
20(2)
11 Diastolic Murmur
22(2)
12 Atrial Fibrillation
24(2)
13 Pericarditis
26(2)
14 Preoperative Cardiac Clearance
28(2)
Chapter 3 Gastroenterology
30(10)
15 Epigastric Pain
30(2)
16 Right Upper Quadrant Pain
32(2)
17 Abnormal Liver Tests
34(2)
18 Cirrhosis
36(2)
19 Diarrhea
38(2)
Chapter 4 Nephrology
40(16)
20 Chronic Renal Failure
40(2)
21 Nephrotic Syndrome
42(2)
22 Hematuria
44(2)
23 Hyponatremia
46(2)
24 Hypernatremia
48(2)
25 Hypokalemia
50(2)
26 Hyperkalemia
52(2)
27 Urinary Tract Infection
54(2)
Chapter 5 Hematology/Oncology
56(24)
28 Anemia
56(2)
29 Thrombocytopenia
58(2)
30 Polycythemia
60(2)
31 Coagulopathy
62(2)
32 Deep Vein Thrombosis
64(2)
33 Lymphoma
66(2)
34 Leukemia
68(2)
35 Breast Mass Evaluation
70(2)
36 Breast Cancer
72(2)
37 Lung Cancer
74(2)
38 Colon Cancer
76(2)
39 Prostate Cancer
78(2)
Chapter 6 Infectious Disease
80(8)
40 Fever of Unknown Origin
80(2)
41 Acute Bacterial Endocarditis
82(2)
42 HIV With Fever
84(2)
43 Cellulitis
86(2)
Chapter 7 Endocrinology
88(18)
44 Diabetes
88(2)
45 Diabetic Ketoacidosis and Hyperosmolar Nonketotic Coma
90(2)
46 Hypothyroidism
92(2)
47 Hyperthyroidism
94(2)
48 Hyperparathyroidism
96(2)
49 Adrenal Insufficiency
98(2)
50 Cushing Syndrome
100(2)
51 Osteoporosis
102(2)
52 Dyslipidemia
104(2)
Chapter 8 Rheumatology
106(18)
53 Low-Back Pain
106(2)
54 Polyarthritis
108(2)
55 Gout
110(2)
56 Rheumatoid Arthritis
112(2)
57 Seronegative Spondyloarthropathies
114(2)
58 Inflammatory Myopathies
116(2)
59 Systemic Lupus Erythematosus
118(2)
60 Vasculitis
120(2)
61 Systemic Sclerosis
122(2)
Chapter 9 Toxicology
124(5)
62 Alcohol Intoxication and Withdrawal
124(2)
63 Cocaine Intoxication and Withdrawal
126(3)
SECTION 2 PEDIATRICS
129(110)
Chapter 10 Newborn Nursery
130(6)
64 Newborn Exam
130(2)
65 Birth Trauma
132(2)
66 Benign Skin Lesions
134(2)
Chapter 11 Pediatric Clinic
136(24)
67 Well-Child Care: Infant
136(2)
68 Well-Child Care: Toddler
138(2)
69 Well-Child Care: Child
140(2)
70 Well-Child Care: Adolescent
142(2)
71 Hyperactive and School-Related Complaints--ADHD
144(2)
72 Chronic Cough and Wheeze--Asthma
146(2)
73 Chronic Runny, Stuffy Nose--Allergic Rhinitis
148(2)
74 Heart Murmur
150(2)
75 Hard Stool or No Stool--Constipation
152(2)
76 Short Stature
154(2)
77 Nosebleeds
156(2)
78 Acne
158(2)
Chapter 12 Pediatric Emergency Room
160(66)
79 Anaphylaxis
160(2)
80 Seizure
162(2)
81 Syncope
164(2)
82 Shortness of Breath, Wheeze, Cough--Asthma
166(2)
83 Infant Who Stops Breathing (Brief Resolved Unexplained Event--BRUE)
168(2)
84 Chest Pain
170(2)
85 Abdominal Pain--Rule Out Appendicitis
172(2)
86 Infant With Projectile Vomiting--Pyloric Stenosis
174(2)
87 Vomiting and Diarrhea--Enteritis
176(2)
88 Bloody Diarrhea--Colitis
178(2)
89 Infant With Episodic Pain and Vomiting--Intussusception
180(2)
90 Chemical Ingestions
182(2)
91 Foreign Body
184(2)
92 Edema--Nephrotic Syndrome
186(2)
93 Easy Bruising or Mucosal Bleeding--ITP
188(2)
94 Fever Without Associated Symptoms
190(2)
95 Fever With Irritability and Vomiting--Meningitis
192(2)
96 Fever With Productive Cough--Pneumonia
194(2)
97 Fever With Barking Cough--Croup
196(2)
98 Fever With Wheezing Cough--Bronchiolitis
198(2)
99 Fever With Runny Nose, Dry Cough--Viral URI
200(2)
100 Fever With Sore Throat--Pharyngitis
202(2)
101 Fever With Dysuria--Urinary Tract Infection
204(2)
102 Fever With Rash--Viral Exanthem
206(2)
103 Fever With Rash, Conjunctivitis, and LAD--Kawasaki Disease
208(2)
104 Rash With Pruritis
210(2)
105 Henoch-Schonlein Purpura
212(2)
106 Bites and Stings
214(2)
107 Limping in Child Without History of Trauma
216(2)
108 Head Trauma
218(2)
109 Limb Trauma
220(2)
110 Suspected Physical Abuse
222(2)
111 Suspected Sexual Abuse
224(2)
Chapter 13 Pediatric Ward
226(13)
112 Inpatient Care
226(2)
113 Dehydration and Intravenous Fluid Management
228(2)
114 Pain Control
230(2)
115 Postoperative Care of the Appendicitis Patient
232(2)
116 Postoperative Care of the Pyloric Stenosis Patient
234(2)
117 Inpatient Care of the Orthopedic Patient
236(3)
SECTION 3 OBSTETRICS AND GYNECOLOGY
239(112)
Chapter 14 Obstetrics Clinic
240(32)
118 Initial Visit
240(2)
119 Second Trimester Visit
242(2)
120 Third Trimester Visit
244(2)
121 Postpartum Visit
246(2)
122 Anemia
248(2)
123 Antiphospholipid Syndrome
250(2)
124 Chronic Hypertension
252(2)
125 Gestational Diabetes Mellitus
254(2)
126 Hyperthyroidism
256(2)
127 Intrauterine Growth Restriction
258(2)
128 Isoimmunization
260(2)
129 Mild Preeclampsia
262(2)
130 Nausea and Vomiting of Pregnancy
264(2)
131 Severe Preeclampsia
266(2)
132 Twin Gestation
268(2)
133 Urinary Tract Infection
270(2)
Chapter 15 Labor and Delivery
272(14)
134 Term Labor
272(2)
135 Third Trimester Bleeding
274(2)
136 Chorioamnionitis
276(2)
137 Labor Dystocia
278(2)
138 Preterm Labor
280(2)
139 Pyelonephritis
282(2)
140 Rupture of Membranes
284(2)
Chapter 16 Maternity Ward
286(10)
141 Postpartum Day 1
286(2)
142 Postpartum Day 2
288(2)
143 Dyspnea
290(2)
144 Postpartum Fever
292(2)
145 Postpartum Hemorrhage
294(2)
Chapter 17 Gynecology Clinic
296(42)
146 Well-Woman Exam
296(2)
147 Abnormal Uterine Bleeding
298(2)
148 Breast Mass
300(2)
149 Chronic Pelvic Pain
302(2)
150 Dysmenorrhea
304(2)
151 Family Planning--Barrier Method
306(2)
152 Family Planning--Depot MPA
308(2)
153 Family Planning--Emergency Contraception
310(2)
154 Family Planning--Intrauterine Device
312(2)
155 Family Planning--Oral Contraceptives
314(2)
156 Family Planning--Sterilization
316(2)
157 Galactorrhea
318(2)
158 Hirsutism
320(2)
159 Infertility
322(2)
160 Menopause
324(2)
161 Perimenopause
326(2)
162 Premenstrual Syndrome
328(2)
163 Recurrent Pregnancy Loss
330(2)
164 Secondary Amenorrhea
332(2)
165 Urinary Incontinence
334(2)
166 Vulvovaginitis
336(2)
Chapter 18 Emergency Room and Consultations
338(13)
167 First Trimester Bleeding--Abortion
338(2)
168 First Trimester Bleeding--Ectopic Pregnancy
340(2)
169 Acute Pelvic Pain
342(2)
170 Gestational Trophoblastic Disease
344(2)
171 Pelvic Inflammatory Disease
346(2)
172 Pelvic Mass
348(3)
SECTION 4 SURGERY AND EMERGENCY MEDICINE
351(94)
Chapter 19 Cardiology
352(20)
173 Aortic Dissection
352(2)
174 Bradycardia/Complete Heart Block
354(2)
175 Cardiac Arrest
356(2)
176 Endocarditis
358(2)
177 Hypertensive Crisis
360(2)
178 Myocardial Infarction
362(2)
179 Palpitations
364(2)
180 Syncope
366(2)
181 Unstable Angina
368(2)
182 Venous Thrombosis
370(2)
Chapter 20 Pulmonary
372(6)
183 Pneumothorax
372(2)
184 Pulmonary Edema
374(2)
185 Pulmonary Embolism
376(2)
Chapter 21 Gastrointestinal
378(24)
186 Abdominal Aortic Aneurysm
378(2)
187 Appendicitis
380(2)
188 Bowel Obstruction
382(2)
189 Biliary Disease
384(2)
190 Diverticulitis
386(2)
191 Foreign-Body Ingestion
388(2)
192 Gastroesophageal Reflux Disease
390(2)
193 Gastrointestinal Bleeding
392(2)
194 Hepatitis
394(2)
195 Ischemic Bowel
396(2)
196 Pancreatitis
398(2)
197 Peptic Ulcer Disease
400(2)
Chapter 22 Genitourinary
402(16)
198 Acute Renal Failure
402(2)
199 Epididymitis
404(2)
200 Hernia
406(2)
201 Hydrocele/Varicocele
408(2)
202 Kidney Stones/Nephrolithiasis
410(2)
203 Pyelonephritis/UTI
412(2)
204 Rhabdomyolysis
414(2)
205 Testicular Torsion
416(2)
Chapter 23 Neurology
418(14)
206 Altered Mental Status
418(2)
207 Headache
420(2)
208 Meningitis
422(2)
209 Seizures
424(2)
210 Stroke
426(2)
211 Vertigo
428(2)
212 Weakness
430(2)
Chapter 24 Trauma
432(13)
213 Animal Bite
432(2)
214 Ankle Sprain
434(2)
215 Burns
436(2)
216 Fracture
438(2)
217 Head Injury
440(2)
218 Laceration
442(3)
SECTION 5 PSYCHIATRY
445(30)
Chapter 25 Guidelines for Conducting a Psychiatric Interview
446(2)
Chapter 26 Personality Disorders
448(2)
Chapter 27 Psychotic Disorders
450(2)
Chapter 28 Anxiety Disorders
452(2)
Chapter 29 Mood Disorders
454(2)
Chapter 30 Dissociative Disorders
456(2)
Chapter 31 Impulse Control Disorders
458(2)
Chapter 32 Neurocognitive Disorders
460(2)
Chapter 33 Somatic Symptoms
462(2)
Chapter 34 Sleep Disorders
464(2)
Chapter 35 Eating Disorders
466(2)
Chapter 36 Sexual Dysfunction
468(2)
Chapter 37 Substance Use Disorders
470(2)
Chapter 38 Posttraumatic Stress Disorder
472(3)
Appendix A 475(2)
Index 477
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