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Category: Nursing

  • [Solved] 612 discussion 4

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    – ## 612discussion4.docx **## 612discussion4.docx** ![icon](https://www.sweetstudy.com/questions/612-discussion-4)**_Case 4_** **Vital signs:** T 99°F, HR 80, RR 18, BP 128/78, BMI 22. **Chief Complaint:** Foul smelling urine, incontinence, restless **Discuss the following:** 1) What additional subj…

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    Assignment Prompt & Instructions

    – ## 612discussion4.docx

    **## 612discussion4.docx**

    ![icon](https://www.sweetstudy.com/questions/612-discussion-4)**_Case 4_**

    **Vital signs:** T 99°F, HR 80, RR 18, BP 128/78, BMI 22.

    **Chief Complaint:** Foul smelling urine, incontinence, restless

    **Discuss the following:**

    1) What additional subjective data are you seeking to include past medical history, social, and relevant family history?
    2) What additional objective data will you be assessing for?
    3) What are the differential diagnoses that you are considering?
    4) What laboratory tests will help you rule out some of the differential diagnoses?
    5) What radiological examinations or additional diagnostic studies would you order?
    6) What treatment and specific information about the prescription that you will give this patient?
    7) What are the potential complications from the treatment ordered?
    8) What additional laboratory tests might you consider ordering?
    9) What additional patient teaching may be needed?
    10) Will you be looking for a consult?

    **Submission Instructions:**

    · Your initial post should be at least 500 words, formatted and cited in current APA style with support from at least 2 academic sources.

    ## image1.png

    **## 612discussion4.docx**

    ![icon](https://www.sweetstudy.com/questions/612-discussion-4)**_Case 4_**

    **Vital signs:** T 99°F, HR 80, RR 18, BP 128/78, BMI 22.

    **Chief Complaint:** Foul smelling urine, incontinence, restless

    **Discuss the following:**

    1) What additional subjective data are you seeking to include past medical history, social, and relevant family history?
    2) What additional objective data will you be assessing for?
    3) What are the differential diagnoses that you are considering?
    4) What laboratory tests will help you rule out some of the differential diagnoses?
    5) What radiological examinations or additional diagnostic studies would you order?
    6) What treatment and specific information about the prescription that you will give this patient?
    7) What are the potential complications from the treatment ordered?
    8) What additional laboratory tests might you consider ordering?
    9) What additional patient teaching may be needed?
    10) Will you be looking for a consult?

    **Submission Instructions:**

    · Your initial post should be at least 500 words, formatted and cited in current APA style with support from at least 2 academic sources.

    ## image1.png

  • [Solved] 612 clinical discussion 4

    ✓ Verified Academic Solution Available

    Executive Solution Overview

    – ## 612discussion4clinical.docx **## 612discussion4clinical.docx** ![icon](https://www.sweetstudy.com/questions/612-clinical-discussion-4)**_Weekly Clinical Experience 4_** Patient came in because she is having trouble sleeping. She is 77 years old Describe your clinical experience for this week. ·…

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    Assignment Prompt & Instructions

    – ## 612discussion4clinical.docx

    **## 612discussion4clinical.docx**

    ![icon](https://www.sweetstudy.com/questions/612-clinical-discussion-4)**_Weekly Clinical Experience 4_**

    Patient came in because she is having trouble sleeping. She is 77 years old

    Describe your clinical experience for this week.

    · Did you face any challenges, any success? If so, what were they?

    · Describe the assessment of a patient, detailing the signs and symptoms (S&S), assessment, plan of care, and at least 3 possible differential diagnosis with rationales.

    · Mention the health promotion intervention for this patient.

    · What did you learn from this week's clinical experience that can beneficial for you as an advanced practice nurse?

    · Support your plan of care with the current peer-reviewed research guideline.

    **Submission Instructions:**

    · Your initial post should be at least 500 words, formatted and cited in current APA style with support from at least 2 academic sources.

    ## image1.png

    **## 612discussion4clinical.docx**

    ![icon](https://www.sweetstudy.com/questions/612-clinical-discussion-4)**_Weekly Clinical Experience 4_**

    Patient came in because she is having trouble sleeping. She is 77 years old

    Describe your clinical experience for this week.

    · Did you face any challenges, any success? If so, what were they?

    · Describe the assessment of a patient, detailing the signs and symptoms (S&S), assessment, plan of care, and at least 3 possible differential diagnosis with rationales.

    · Mention the health promotion intervention for this patient.

    · What did you learn from this week's clinical experience that can beneficial for you as an advanced practice nurse?

    · Support your plan of care with the current peer-reviewed research guideline.

    **Submission Instructions:**

    · Your initial post should be at least 500 words, formatted and cited in current APA style with support from at least 2 academic sources.

    ## image1.png

  • [Solved] WK 2 Res Blog

    ✓ Verified Academic Solution Available

    Executive Solution Overview

    – ## WK3BLOGTELE.docx **## WK3BLOGTELE.docx** Blog: How Has Nursing Informatics and Technology Impacted Your Practice? ![A person looking at an x-ray AI-generated content may be incorrect.](https://www.sweetstudy.com/questions/wk-2-res-blog) For this Discussion, you will explore the impact of digita…

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    Assignment Prompt & Instructions

    – ## WK3BLOGTELE.docx

    **## WK3BLOGTELE.docx**

    Blog: How Has Nursing Informatics and Technology Impacted Your Practice?

    ![A person looking at an x-ray AI-generated content may be incorrect.](https://www.sweetstudy.com/questions/wk-2-res-blog)

    For this Discussion, you will explore the impact of digital technology on nursing practice. Consider the influence these technologies may have on nursing practice, and what skills you might need to hone in on in order to address these needs.

    Resources

    Be sure to review the Learning Resources before completing this activity.
    Click the weekly resources link to access the resources.

    [**WEEKLY RESOURCES**](https://waldenu.instructure.com/courses/175732/modules/items/6883256)

    Learning Resources

    [Required Readings](https://waldenu.instructure.com/courses/175732/pages/week-3-learning-resources?module_item_id=6883256)

    · Sipes, C. (2025).
    _Project management for the advanced practice nurse_ (3rd ed.). Springer Publishing.

    · Chapter 4, “Planning: Project Management—Phase 2” (pp. 85–130)

    · American Nurses Association. (2015).
    [_Nursing informaticsLinks to an external site._](https://search.ebscohost.com/login.aspx?direct=true&db=nlebk&AN=1021761&site=eds-live&scope=site&authtype=shib&custid=s6527200) _: Scope and standards of practice_  (2nd ed.).

    · “Evolution of Nursing Informatics Competencies” (pp. 37–41)

    · “The Future of Nursing Informatics” (pp. 52–62)

    · “Standard 3: Outcomes Identification” (p. 71)

    · “Standard 4: Planning” (p. 72)

    · American Hospital Association. (n.d.).
    [_Innovative models of care delivery: Addressing transitions across the care continuumLinks to an external site._](https://www.aha.org/system/files/media/file/2019/05/Innovative-Models-of-Care.pdf) . https://www.aha.org/system/files/media/file/2019/05/Innovative-Models-of-Care.pdf

    · Guest in VSee. (2020).
    [_7 ways technology is transforming the nursing field_ Links to an external site.](https://vsee.com/blog/technology-transforming-nursing-field). VSee.com. https://vsee.com/blog/technology-transforming-nursing-field

    · The Medical Futurist. (2020).
    [_10 ways technology is changing healthcare_ Links to an external site.](https://medicalfuturist.com/ten-ways-technology-changing-healthcare/). https://medicalfuturist.com/ten-ways-technology-changing-healthcare/

    [Required Media](https://waldenu.instructure.com/courses/175732/pages/week-3-learning-resources?module_item_id=6883256)

    · Schade, M. (2016, January 11).
    [_How to do a GAP Analysis_ Links to an external site.](https://www.youtube.com/watch?v=8xXReyiFtBY). [Video]. YouTube. https://www.youtube.com/watch?v=8xXReyiFtBY

    · Project Manager. (2014, June 2).
    [_What is a work breakdown structureLinks to an external site._](https://www.youtube.com/watch?v=wEWhnodF6ig) _?_ [Video]. YouTube. https://www.youtube.com/watch?v=wEWhnodF6ig

    · Project Manager. (2016, March 11).
    [_Gantt Charts, Simplified – The Project Management TrainingLinks to an external site._](https://www.youtube.com/watch?v=cGkHjby1xKM) _._ [Video]. YouTube. https://www.youtube.com/watch?v=cGkHjby1xKM

    [Optional Resources](https://waldenu.instructure.com/courses/175732/pages/week-3-learning-resources?module_item_id=6883256)

    · Rew, L., Cauvin, S., Cengiz, A., Pretorius, K., & Johnson, K. (2020).
    [Application of project management tools and techniques to support nursing intervention researchLinks to an external site.](https://go.openathens.net/redirector/waldenu.edu?url=https://www.sciencedirect.com/science/article/pii/S0029655419304476?via%3Dihub).
    _Nursing Outlook, 68_ (4), 396–405. https://doi.org/10.1016/j.outlook.2020.01.007

    [Previous](https://waldenu.instructure.com/courses/175732/modules/items/6883248)

    [Next](https://waldenu.instructure.com/courses/175732/modules/items/6883261)

    To Prepare

    · Consider your nursing background and professional interests as you view the video.

    · What potential skills, knowledge, or competencies to ensure quality of care and safety improvements, might you need to develop for your healthcare organization or nursing practice to ensure continued quality care and safety?

    By Day 3 of Week 3

    **Post** a blog to address the following:

    · Explore the pivotal role of informatics competencies in enhancing the quality of care and safety in your nursing practice.

    By Day 6 of Week 3

    **Read** a selection of your colleagues’ blog posts and
    **respond** to
    **at least two** of your colleagues on
    **two different days** by expanding upon their responses or sharing additional or alternative perspectives.

    RESPOND TO THIS DISCUSSION POST

    Lori

    Nursing informatics competencies enhance the quality of care and safety within the nursing profession. Nursing informatics competency is to analyze healthcare information communication technology in order to reduce risks and improve care for patients. Nursing informatics and technology have positively impacted the nursing profession. This technology allows nurses to deliver evidence based care to their patients. Within my nursing practice of oncology, we are able to use oncology data and workflows with EHR’s. As stated in Parikh et al., (2022), EHR’s  are the core of  health information technology that stores patient’s data for the primary purpose to support continuing efficient, and quality integrated health care. Nurses are able to maintain accurate and comprehensive documentation which facilitates better communication among healthcare providers and reduces errors. With the use of EHR’s in my oncology practice, there has been a reduction of medication errors and chemotherapy errors. EHR’s may result in improved and more efficient care, better care coordination and patient safety (Harris, et al., 2023). Patient portals is another technology tool that can help within the oncology department as well as all healthcare organizations by helping patients and providers have open communication, requesting refills and making appointments, access health records and lab results. As stated in Gerber et al., (2017), electronic portals provide patients with real time access to their personal patient health records and communication with healthcare providers.  Nursing informatics and other technological methods will continue to help shape the healthcare system into the future.

    References:

    Gerber, D.E., Beg, M.S., Duncan, T., Gill, M., & Lee S.J.C. (2017). Oncology nursing

                perceptions of patient electronic portal use: a qualitative analysis.
    _Oncology Nursing_

    _Forum 1_(44):165-170. Doi:10.1188/17.ONF.165-170.

    Harris, R., Machin, J., Deo , J., Sindhu, L., Kambo, N., & Cremer, N. (2023). Electronic

                health records: Qualitative systematic review.
    _Canadian Journal of Nursing_

    _Informatics 18_(3).

    Parikh, R.B., Basen-Enquist, K., Bradley, C., Estrin, D., Levy, M., Lichtenfeld, J.L., Malin, B.,

                McGraw, D., Meropol, N.J., Oyer, R.A., & Shulman, L.N. (2022). Digital health

                applications in oncology: An opportunity to seize.
    _Journal of the National Cancer_

    _Institute 114_(10):1338-1339. Doi:10.1093/jnci/djac108.

    **Reply**

    ## image1.jpeg

    **## WK3BLOGTELE.docx**

    Blog: How Has Nursing Informatics and Technology Impacted Your Practice?

    ![A person looking at an x-ray AI-generated content may be incorrect.](https://www.sweetstudy.com/questions/wk-2-res-blog)

    For this Discussion, you will explore the impact of digital technology on nursing practice. Consider the influence these technologies may have on nursing practice, and what skills you might need to hone in on in order to address these needs.

    Resources

    Be sure to review the Learning Resources before completing this activity.
    Click the weekly resources link to access the resources.

    [**WEEKLY RESOURCES**](https://waldenu.instructure.com/courses/175732/modules/items/6883256)

    Learning Resources

    [Required Readings](https://waldenu.instructure.com/courses/175732/pages/week-3-learning-resources?module_item_id=6883256)

    · Sipes, C. (2025).
    _Project management for the advanced practice nurse_ (3rd ed.). Springer Publishing.

    · Chapter 4, “Planning: Project Management—Phase 2” (pp. 85–130)

    · American Nurses Association. (2015).
    [_Nursing informaticsLinks to an external site._](https://search.ebscohost.com/login.aspx?direct=true&db=nlebk&AN=1021761&site=eds-live&scope=site&authtype=shib&custid=s6527200) _: Scope and standards of practice_  (2nd ed.).

    · “Evolution of Nursing Informatics Competencies” (pp. 37–41)

    · “The Future of Nursing Informatics” (pp. 52–62)

    · “Standard 3: Outcomes Identification” (p. 71)

    · “Standard 4: Planning” (p. 72)

    · American Hospital Association. (n.d.).
    [_Innovative models of care delivery: Addressing transitions across the care continuumLinks to an external site._](https://www.aha.org/system/files/media/file/2019/05/Innovative-Models-of-Care.pdf) . https://www.aha.org/system/files/media/file/2019/05/Innovative-Models-of-Care.pdf

    · Guest in VSee. (2020).
    [_7 ways technology is transforming the nursing field_ Links to an external site.](https://vsee.com/blog/technology-transforming-nursing-field). VSee.com. https://vsee.com/blog/technology-transforming-nursing-field

    · The Medical Futurist. (2020).
    [_10 ways technology is changing healthcare_ Links to an external site.](https://medicalfuturist.com/ten-ways-technology-changing-healthcare/). https://medicalfuturist.com/ten-ways-technology-changing-healthcare/

    [Required Media](https://waldenu.instructure.com/courses/175732/pages/week-3-learning-resources?module_item_id=6883256)

    · Schade, M. (2016, January 11).
    [_How to do a GAP Analysis_ Links to an external site.](https://www.youtube.com/watch?v=8xXReyiFtBY). [Video]. YouTube. https://www.youtube.com/watch?v=8xXReyiFtBY

    · Project Manager. (2014, June 2).
    [_What is a work breakdown structureLinks to an external site._](https://www.youtube.com/watch?v=wEWhnodF6ig) _?_ [Video]. YouTube. https://www.youtube.com/watch?v=wEWhnodF6ig

    · Project Manager. (2016, March 11).
    [_Gantt Charts, Simplified – The Project Management TrainingLinks to an external site._](https://www.youtube.com/watch?v=cGkHjby1xKM) _._ [Video]. YouTube. https://www.youtube.com/watch?v=cGkHjby1xKM

    [Optional Resources](https://waldenu.instructure.com/courses/175732/pages/week-3-learning-resources?module_item_id=6883256)

    · Rew, L., Cauvin, S., Cengiz, A., Pretorius, K., & Johnson, K. (2020).
    [Application of project management tools and techniques to support nursing intervention researchLinks to an external site.](https://go.openathens.net/redirector/waldenu.edu?url=https://www.sciencedirect.com/science/article/pii/S0029655419304476?via%3Dihub).
    _Nursing Outlook, 68_ (4), 396–405. https://doi.org/10.1016/j.outlook.2020.01.007

    [Previous](https://waldenu.instructure.com/courses/175732/modules/items/6883248)

    [Next](https://waldenu.instructure.com/courses/175732/modules/items/6883261)

    To Prepare

    · Consider your nursing background and professional interests as you view the video.

    · What potential skills, knowledge, or competencies to ensure quality of care and safety improvements, might you need to develop for your healthcare organization or nursing practice to ensure continued quality care and safety?

    By Day 3 of Week 3

    **Post** a blog to address the following:

    · Explore the pivotal role of informatics competencies in enhancing the quality of care and safety in your nursing practice.

    By Day 6 of Week 3

    **Read** a selection of your colleagues’ blog posts and
    **respond** to
    **at least two** of your colleagues on
    **two different days** by expanding upon their responses or sharing additional or alternative perspectives.

    RESPOND TO THIS DISCUSSION POST

    Lori

    Nursing informatics competencies enhance the quality of care and safety within the nursing profession. Nursing informatics competency is to analyze healthcare information communication technology in order to reduce risks and improve care for patients. Nursing informatics and technology have positively impacted the nursing profession. This technology allows nurses to deliver evidence based care to their patients. Within my nursing practice of oncology, we are able to use oncology data and workflows with EHR’s. As stated in Parikh et al., (2022), EHR’s  are the core of  health information technology that stores patient’s data for the primary purpose to support continuing efficient, and quality integrated health care. Nurses are able to maintain accurate and comprehensive documentation which facilitates better communication among healthcare providers and reduces errors. With the use of EHR’s in my oncology practice, there has been a reduction of medication errors and chemotherapy errors. EHR’s may result in improved and more efficient care, better care coordination and patient safety (Harris, et al., 2023). Patient portals is another technology tool that can help within the oncology department as well as all healthcare organizations by helping patients and providers have open communication, requesting refills and making appointments, access health records and lab results. As stated in Gerber et al., (2017), electronic portals provide patients with real time access to their personal patient health records and communication with healthcare providers.  Nursing informatics and other technological methods will continue to help shape the healthcare system into the future.

    References:

    Gerber, D.E., Beg, M.S., Duncan, T., Gill, M., & Lee S.J.C. (2017). Oncology nursing

                perceptions of patient electronic portal use: a qualitative analysis.
    _Oncology Nursing_

    _Forum 1_(44):165-170. Doi:10.1188/17.ONF.165-170.

    Harris, R., Machin, J., Deo , J., Sindhu, L., Kambo, N., & Cremer, N. (2023). Electronic

                health records: Qualitative systematic review.
    _Canadian Journal of Nursing_

    _Informatics 18_(3).

    Parikh, R.B., Basen-Enquist, K., Bradley, C., Estrin, D., Levy, M., Lichtenfeld, J.L., Malin, B.,

                McGraw, D., Meropol, N.J., Oyer, R.A., & Shulman, L.N. (2022). Digital health

                applications in oncology: An opportunity to seize.
    _Journal of the National Cancer_

    _Institute 114_(10):1338-1339. Doi:10.1093/jnci/djac108.

    **Reply**

    ## image1.jpeg

  • [Solved] 612 soap 2

    ✓ Verified Academic Solution Available

    Executive Solution Overview

    – ## 612soap2.docx – ## SOAPNOTETEMPLATEBLANK.docx – SOAPNoteRubric.pdf **## 612soap2.docx** ![icon](https://www.sweetstudy.com/questions/612-soap-2)**_SOAP Note 2_** Patient is a 77 year male coming in because he keeps on wetting the bed. Has no history of surgeries. Has a wife and 2 kids. No famil…

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    Have this question answered from scratch according to your specific instructions and deadline.

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    Assignment Prompt & Instructions

    – ## 612soap2.docx

    – ## SOAPNOTETEMPLATEBLANK.docx

    – SOAPNoteRubric.pdf

    **## 612soap2.docx**

    ![icon](https://www.sweetstudy.com/questions/612-soap-2)**_SOAP Note 2_**

    Patient is a 77 year male coming in because he keeps on wetting the bed. Has no history of surgeries. Has a wife and 2 kids. No family histories. Wife does have type 2 diabetes. And he has mild hypertension but that started in his early 60’s.

    A SOAP note is a method of documentation employed by healthcare providers to record and communicate patient information in a clear, structured, and in an organized manner. This assignment will provide students with the necessary tools to document patient care effectively, enhance their clinical skills, and prepare them for their roles as competent healthcare providers.

    **Instructions:**

    SOAP is an acronym that stands for Subjective, Objective, Assessment, and Plan. The episodic SOAP note is to be written using the attached template below.

    For all the SOAP note assignments, you will write a SOAP note about one of your patients and use the following acronym:

    | | |
    | — | — |
    | **S** = | Subjective data: Patient’s Chief Complaint (CC). |
    | **O** = | Objective data: Including client behavior, physical assessment, vital signs, and meds. |
    | **A** = | Assessment: Diagnosis of the patient's condition. Include differential diagnosis. |
    | **P** = | Plan: Treatment, diagnostic testing, and follow up |

    [Click here to access and download the SOAP Note Template](https://stu.instructure.com/courses/45516/files/3584005?wrap=1) [Download Click here to access and download the SOAP Note Template](https://stu.instructure.com/courses/45516/files/3584005/download?download_frd=1)

    **Submission Instructions:**

    · Your SOAP note should be clear and concise and students will lose points for improper grammar, punctuation, and misspellings.

    · You must use the template provided. Turnitin will recognize the template and not score against it.

    ## image1.png

    **## SOAPNOTETEMPLATEBLANK.docx**

    | | |
    | — | — |
    | SOAP NOTE TEMPLATE<br>Review the Rubric for more Guidance |
    | _Demographics_ | |
    | _Chief Complaint (Reason for seeking health care)_ | |
    | _History of Present Illness (HPI)_ | |
    | _Allergies_ | |
    | _Review of Systems (ROS)_ | General: <br>HEENT:<br>Neck: <br>Lungs:<br>Cardio<br>Breast: <br>GI: <br>M/F genital:<br>GU: <br>Neuro<br>Musculo:<br>Activity:<br>Psychosocial: <br>Derm: <br>Nutrition:<br>Sleep/Rest:<br>LMP: <br>STI Hx: |
    | _Vital Signs_ | |
    | _Labs_ | |
    | _Medications_ | |
    | _Past Medical History_ | |
    | _Past Surgical History_ | |
    | _Family History_ | |
    | _Social History_ | |
    | _Health Maintenance/ Screenings_ | |
    | _Physical Examination_ | General: <br>HEENT:<br>Neck: <br>Lungs:<br>Cardio<br>Breast: <br>GI: <br>M/F genital:<br>GU: <br>Neuro<br>Musculo:<br>Activity:<br>Psychosocial: <br>Derm: |
    | _Diagnosis_ | |
    | _Differential Diagnosis_ | |
    | _ICD 10 Coding_ | |
    | _Pharmacologic treatment plan_ | |
    | _Diagnostic/Lab Testing_ | |
    | _Education_ | |
    | _Anticipatory Guidance_ | |
    | _Follow up plan_ | |
    | _Prescription_ | See Below (scroll down) |
    | _References_ | |
    | _Grammar_ | |

    | |
    | — |
    | EA#: 101010101 STU Clinic LIC# 10000000 |
    | Tel: (000) 555-1234 FAX: (000) 555-12222 |
    | Patient Name: (Initials)______________________________ Age ___________<br>Date: _______________<br>RX ______________________________________<br>SIG:<br>Dispense: ___________ Refill: _________________<br>No Substitution<br> <br>Signature:____________________________________________________________ |

    Signature (with appropriate credentials):_____________________________________

    References (must use current evidence-based guidelines used to guide the care [Mandatory])

    **SOAPNoteRubric.pdf**

    This file is too large to display. [View in new window](https://www.sweetstudy.com/files/soapnoterubric-pdf-10318275)

    **SOAPNoteRubric.pdf**

    This file is too large to display. [View in new window](https://www.sweetstudy.com/files/soapnoterubric-pdf-10318275)

    **## 612soap2.docx**

    ![icon](https://www.sweetstudy.com/questions/612-soap-2)**_SOAP Note 2_**

    Patient is a 77 year male coming in because he keeps on wetting the bed. Has no history of surgeries. Has a wife and 2 kids. No family histories. Wife does have type 2 diabetes. And he has mild hypertension but that started in his early 60’s.

    A SOAP note is a method of documentation employed by healthcare providers to record and communicate patient information in a clear, structured, and in an organized manner. This assignment will provide students with the necessary tools to document patient care effectively, enhance their clinical skills, and prepare them for their roles as competent healthcare providers.

    **Instructions:**

    SOAP is an acronym that stands for Subjective, Objective, Assessment, and Plan. The episodic SOAP note is to be written using the attached template below.

    For all the SOAP note assignments, you will write a SOAP note about one of your patients and use the following acronym:

    | | |
    | — | — |
    | **S** = | Subjective data: Patient’s Chief Complaint (CC). |
    | **O** = | Objective data: Including client behavior, physical assessment, vital signs, and meds. |
    | **A** = | Assessment: Diagnosis of the patient's condition. Include differential diagnosis. |
    | **P** = | Plan: Treatment, diagnostic testing, and follow up |

    [Click here to access and download the SOAP Note Template](https://stu.instructure.com/courses/45516/files/3584005?wrap=1) [Download Click here to access and download the SOAP Note Template](https://stu.instructure.com/courses/45516/files/3584005/download?download_frd=1)

    **Submission Instructions:**

    · Your SOAP note should be clear and concise and students will lose points for improper grammar, punctuation, and misspellings.

    · You must use the template provided. Turnitin will recognize the template and not score against it.

    ## image1.png

    **## SOAPNOTETEMPLATEBLANK.docx**

    | | |
    | — | — |
    | SOAP NOTE TEMPLATE<br>Review the Rubric for more Guidance |
    | _Demographics_ | |
    | _Chief Complaint (Reason for seeking health care)_ | |
    | _History of Present Illness (HPI)_ | |
    | _Allergies_ | |
    | _Review of Systems (ROS)_ | General: <br>HEENT:<br>Neck: <br>Lungs:<br>Cardio<br>Breast: <br>GI: <br>M/F genital:<br>GU: <br>Neuro<br>Musculo:<br>Activity:<br>Psychosocial: <br>Derm: <br>Nutrition:<br>Sleep/Rest:<br>LMP: <br>STI Hx: |
    | _Vital Signs_ | |
    | _Labs_ | |
    | _Medications_ | |
    | _Past Medical History_ | |
    | _Past Surgical History_ | |
    | _Family History_ | |
    | _Social History_ | |
    | _Health Maintenance/ Screenings_ | |
    | _Physical Examination_ | General: <br>HEENT:<br>Neck: <br>Lungs:<br>Cardio<br>Breast: <br>GI: <br>M/F genital:<br>GU: <br>Neuro<br>Musculo:<br>Activity:<br>Psychosocial: <br>Derm: |
    | _Diagnosis_ | |
    | _Differential Diagnosis_ | |
    | _ICD 10 Coding_ | |
    | _Pharmacologic treatment plan_ | |
    | _Diagnostic/Lab Testing_ | |
    | _Education_ | |
    | _Anticipatory Guidance_ | |
    | _Follow up plan_ | |
    | _Prescription_ | See Below (scroll down) |
    | _References_ | |
    | _Grammar_ | |

    | |
    | — |
    | EA#: 101010101 STU Clinic LIC# 10000000 |
    | Tel: (000) 555-1234 FAX: (000) 555-12222 |
    | Patient Name: (Initials)______________________________ Age ___________<br>Date: _______________<br>RX ______________________________________<br>SIG:<br>Dispense: ___________ Refill: _________________<br>No Substitution<br> <br>Signature:____________________________________________________________ |

    Signature (with appropriate credentials):_____________________________________

    References (must use current evidence-based guidelines used to guide the care [Mandatory])

    **SOAPNoteRubric.pdf**

    This file is too large to display. [View in new window](https://www.sweetstudy.com/files/soapnoterubric-pdf-10318275)

    **## 612soap2.docx**

    ![icon](https://www.sweetstudy.com/questions/612-soap-2)**_SOAP Note 2_**

    Patient is a 77 year male coming in because he keeps on wetting the bed. Has no history of surgeries. Has a wife and 2 kids. No family histories. Wife does have type 2 diabetes. And he has mild hypertension but that started in his early 60’s.

    A SOAP note is a method of documentation employed by healthcare providers to record and communicate patient information in a clear, structured, and in an organized manner. This assignment will provide students with the necessary tools to document patient care effectively, enhance their clinical skills, and prepare them for their roles as competent healthcare providers.

    **Instructions:**

    SOAP is an acronym that stands for Subjective, Objective, Assessment, and Plan. The episodic SOAP note is to be written using the attached template below.

    For all the SOAP note assignments, you will write a SOAP note about one of your patients and use the following acronym:

    | | |
    | — | — |
    | **S** = | Subjective data: Patient’s Chief Complaint (CC). |
    | **O** = | Objective data: Including client behavior, physical assessment, vital signs, and meds. |
    | **A** = | Assessment: Diagnosis of the patient's condition. Include differential diagnosis. |
    | **P** = | Plan: Treatment, diagnostic testing, and follow up |

    [Click here to access and download the SOAP Note Template](https://stu.instructure.com/courses/45516/files/3584005?wrap=1) [Download Click here to access and download the SOAP Note Template](https://stu.instructure.com/courses/45516/files/3584005/download?download_frd=1)

    **Submission Instructions:**

    · Your SOAP note should be clear and concise and students will lose points for improper grammar, punctuation, and misspellings.

    · You must use the template provided. Turnitin will recognize the template and not score against it.

    ## image1.png

    **## SOAPNOTETEMPLATEBLANK.docx**

    | | |
    | — | — |
    | SOAP NOTE TEMPLATE<br>Review the Rubric for more Guidance |
    | _Demographics_ | |
    | _Chief Complaint (Reason for seeking health care)_ | |
    | _History of Present Illness (HPI)_ | |
    | _Allergies_ | |
    | _Review of Systems (ROS)_ | General: <br>HEENT:<br>Neck: <br>Lungs:<br>Cardio<br>Breast: <br>GI: <br>M/F genital:<br>GU: <br>Neuro<br>Musculo:<br>Activity:<br>Psychosocial: <br>Derm: <br>Nutrition:<br>Sleep/Rest:<br>LMP: <br>STI Hx: |
    | _Vital Signs_ | |
    | _Labs_ | |
    | _Medications_ | |
    | _Past Medical History_ | |
    | _Past Surgical History_ | |
    | _Family History_ | |
    | _Social History_ | |
    | _Health Maintenance/ Screenings_ | |
    | _Physical Examination_ | General: <br>HEENT:<br>Neck: <br>Lungs:<br>Cardio<br>Breast: <br>GI: <br>M/F genital:<br>GU: <br>Neuro<br>Musculo:<br>Activity:<br>Psychosocial: <br>Derm: |
    | _Diagnosis_ | |
    | _Differential Diagnosis_ | |
    | _ICD 10 Coding_ | |
    | _Pharmacologic treatment plan_ | |
    | _Diagnostic/Lab Testing_ | |
    | _Education_ | |
    | _Anticipatory Guidance_ | |
    | _Follow up plan_ | |
    | _Prescription_ | See Below (scroll down) |
    | _References_ | |
    | _Grammar_ | |

    | |
    | — |
    | EA#: 101010101 STU Clinic LIC# 10000000 |
    | Tel: (000) 555-1234 FAX: (000) 555-12222 |
    | Patient Name: (Initials)______________________________ Age ___________<br>Date: _______________<br>RX ______________________________________<br>SIG:<br>Dispense: ___________ Refill: _________________<br>No Substitution<br> <br>Signature:____________________________________________________________ |

    Signature (with appropriate credentials):_____________________________________

    References (must use current evidence-based guidelines used to guide the care [Mandatory])

    **SOAPNoteRubric.pdf**

    This file is too large to display. [View in new window](https://www.sweetstudy.com/files/soapnoterubric-pdf-10318275)

    – 1
    – 2
    – 3

  • [Solved] Case Study

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    – ## CaseStudyDiscussion2.docx **## CaseStudyDiscussion2.docx** **Please follow APA format, add citations and references. Document will be verified for plagiarism and AI use. Thank you!** Case Study Discussion 2 **Study Discussion Instructions** **Scenario: A 32 year old female reports a history of …

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    – ## CaseStudyDiscussion2.docx

    **## CaseStudyDiscussion2.docx**

    **Please follow APA format, add citations and references. Document will be verified for plagiarism and AI use. Thank you!**

    Case Study Discussion 2

    **Study Discussion Instructions**

    **Scenario: A 32 year old female reports a history of depression, crying spells, substance abuse, and behaviors that include eating and sleeping very little, talking excessively, and gambling.  The patient is sarcastic during the initial evaluation.**

    Based on this scenario, respond to the following questions:

    2.
    **Does this case potentially involve a patient with a unipolar or bipolar condition and why? What do you know about the etiology of this condition?**

    3.
    **According to the DSM V-TR, what is the criteria for the probable psychiatric condition?**

    4.
    **What treatment options will you offer this patient and why? (Provide non-pharmacological and pharmacological interventions, including nursing interventions)**

    5.
    **What do you know about the mechanism of action of mood stabilizers? What labs should you order prior to or during the course of treatment for patients on mood stabilizers and why?**

    **## CaseStudyDiscussion2.docx**

    **Please follow APA format, add citations and references. Document will be verified for plagiarism and AI use. Thank you!**

    Case Study Discussion 2

    **Study Discussion Instructions**

    **Scenario: A 32 year old female reports a history of depression, crying spells, substance abuse, and behaviors that include eating and sleeping very little, talking excessively, and gambling.  The patient is sarcastic during the initial evaluation.**

    Based on this scenario, respond to the following questions:

    2.
    **Does this case potentially involve a patient with a unipolar or bipolar condition and why? What do you know about the etiology of this condition?**

    3.
    **According to the DSM V-TR, what is the criteria for the probable psychiatric condition?**

    4.
    **What treatment options will you offer this patient and why? (Provide non-pharmacological and pharmacological interventions, including nursing interventions)**

    5.
    **What do you know about the mechanism of action of mood stabilizers? What labs should you order prior to or during the course of treatment for patients on mood stabilizers and why?**

  • [Solved] CASE STUDY ANELYS

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    Executive Solution Overview

    PLEASE SEE ATTACHED DOCUMENT FOR SEE CONTEXT AND REQUIREMENTS 2 PAGES DUE DATE JUNE 12, 2025 – ## CASESTUDYANDREQUIREMENT.pdf **## CASESTUDYANDREQUIREMENT.pdf** Week 6 case study Bertha, a 58 – year – old Hispanic female, presents to the primary care clinic to establish care. She states that in 1985…

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    Assignment Prompt & Instructions

    PLEASE SEE ATTACHED DOCUMENT FOR SEE CONTEXT AND REQUIREMENTS
    2 PAGES
    DUE DATE JUNE 12, 2025

    – ## CASESTUDYANDREQUIREMENT.pdf

    **## CASESTUDYANDREQUIREMENT.pdf**

    Week 6 case study

    Bertha, a 58 – year – old Hispanic female, presents to the primary care clinic to establish care. She states
    that in 1985 she received a blood transfusion after sustained an MVA. She had tested positive for hepatitis
    C virus ( HCV ) in the past, but ignored any advice regarding treatment options. She brings a previous lab
    result with her today that shows :(ALT) level of 85 IU/mL (range 8 – 35 IU/mL). The lab form also states,
    “ HCV antibody is positive by enzyme immunoassay — confirmation is suggested. The patient also
    arrived with diagnosis with exacerbation of A-Fib (pulse 110 beats per mint. and COPD exacerbation as
    well (O2 sat: 87%)

    Past medical h story: Hypertension, dyslipidemia, hepatitis C.

    Family history: Unremarkable

    Social history: She works as a case manager of an HMO and is married with 2 children. Denies use of
    illegal drugs, denies alcohol abuse, and has no tattoos.

    Medications: HCTZ, 12,5 mg daily; Atorvastatin 20 mg daily, Metoprolol Succinate 25 mg and Pro-Air
    HFA 90mcg one puff q 4- 6 hrs as needed x pain.

    Allergies: No known drug or food allergies.

    OBJECTIVE General a ppearance: 58 – year – old female; pleasant, in no acute distress; good eye contact.
    Vital signs: T: 96.8; P: 110; RR: 23; SaO 2 : 87; BP: 150/100. Her weight is 214 lb, and her height is 6.3
    inches.

    HEENT : Negative. Neck: Thyroid nonpalpable. No lymphadenopathy.

    Cardiovascular: A-fib rhythm. irregular and rapid heartbeat.

    Respiratory: Crackles and Wheezing.

    Abdomen: Mild tenderness in right upper quadrant. BS x 4 no bruits. Nondistended, soft. No
    organomegaly. No ascites.

    Neurological: A & O × 4, CN II – XII grossly intact.

    Depression scale: negative. Musculoskeletal: Full ROM. No deformities. Muscle strength is 5/5.

    CRITICAL THINKING

    Which diagnostic or imaging studies should be considered confirm the

    diagnosis?

    What is the most likely differential diagnosis?

    What is your plan of treatment?

    Are there any emergency referrals needed?

    What is first line treatment for AFib in patients with the mentioned comorbidities?

    What is the first line of treatment for COPD exacerbation?

    REQUIREMENTS

    2 PAGES

    NO MORE THAN 10% PLAGIARISM OR STUDENT PAPER SIMILARITY ALLOWED

    MUST BE ORIGINAL AND UNIQUE WORK

    4 REFERENCES SCHOLARLY JOURNALS OR BOOKS NO OLDER THAN 5 YEARS, NO
    BOOKS REFERENCES

    REQUIRED IN-TEXT CITATIONS

    APA 7TH EDITION FORMAT

    CHECK YOUR GRAMMAR AND SPELLING

    DUE DATE JUNE 12 , 2025 NO LATER

    DO YOUR BEST

    MUST BE ORIGINAL EACH WORD IN INDIVIDUAL

    **## CASESTUDYANDREQUIREMENT.pdf**

    Week 6 case study

    Bertha, a 58 – year – old Hispanic female, presents to the primary care clinic to establish care. She states
    that in 1985 she received a blood transfusion after sustained an MVA. She had tested positive for hepatitis
    C virus ( HCV ) in the past, but ignored any advice regarding treatment options. She brings a previous lab
    result with her today that shows :(ALT) level of 85 IU/mL (range 8 – 35 IU/mL). The lab form also states,
    “ HCV antibody is positive by enzyme immunoassay — confirmation is suggested. The patient also
    arrived with diagnosis with exacerbation of A-Fib (pulse 110 beats per mint. and COPD exacerbation as
    well (O2 sat: 87%)

    Past medical h story: Hypertension, dyslipidemia, hepatitis C.

    Family history: Unremarkable

    Social history: She works as a case manager of an HMO and is married with 2 children. Denies use of
    illegal drugs, denies alcohol abuse, and has no tattoos.

    Medications: HCTZ, 12,5 mg daily; Atorvastatin 20 mg daily, Metoprolol Succinate 25 mg and Pro-Air
    HFA 90mcg one puff q 4- 6 hrs as needed x pain.

    Allergies: No known drug or food allergies.

    OBJECTIVE General a ppearance: 58 – year – old female; pleasant, in no acute distress; good eye contact.
    Vital signs: T: 96.8; P: 110; RR: 23; SaO 2 : 87; BP: 150/100. Her weight is 214 lb, and her height is 6.3
    inches.

    HEENT : Negative. Neck: Thyroid nonpalpable. No lymphadenopathy.

    Cardiovascular: A-fib rhythm. irregular and rapid heartbeat.

    Respiratory: Crackles and Wheezing.

    Abdomen: Mild tenderness in right upper quadrant. BS x 4 no bruits. Nondistended, soft. No
    organomegaly. No ascites.

    Neurological: A & O × 4, CN II – XII grossly intact.

    Depression scale: negative. Musculoskeletal: Full ROM. No deformities. Muscle strength is 5/5.

    CRITICAL THINKING

    Which diagnostic or imaging studies should be considered confirm the

    diagnosis?

    What is the most likely differential diagnosis?

    What is your plan of treatment?

    Are there any emergency referrals needed?

    What is first line treatment for AFib in patients with the mentioned comorbidities?

    What is the first line of treatment for COPD exacerbation?

    REQUIREMENTS

    2 PAGES

    NO MORE THAN 10% PLAGIARISM OR STUDENT PAPER SIMILARITY ALLOWED

    MUST BE ORIGINAL AND UNIQUE WORK

    4 REFERENCES SCHOLARLY JOURNALS OR BOOKS NO OLDER THAN 5 YEARS, NO
    BOOKS REFERENCES

    REQUIRED IN-TEXT CITATIONS

    APA 7TH EDITION FORMAT

    CHECK YOUR GRAMMAR AND SPELLING

    DUE DATE JUNE 12 , 2025 NO LATER

    DO YOUR BEST

    MUST BE ORIGINAL EACH WORD IN INDIVIDUAL

  • [Solved] MELI CASE STUDY

    ✓ Verified Academic Solution Available

    Executive Solution Overview

    PLEASE SEE ATTACHED DOCUMENT FOR SEE CONTEXT AND REQUIREMENTS 2 PAGES DUE DATE JUNE 12, 2025 – ## CASESTUDYANDREQUIREMENT.pdf **## CASESTUDYANDREQUIREMENT.pdf** Week 6 case study Bertha, a 58 – year – old Hispanic female, presents to the primary care clinic to establish care. She states that in 1985…

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    Assignment Prompt & Instructions

    PLEASE SEE ATTACHED DOCUMENT FOR SEE CONTEXT AND REQUIREMENTS
    2 PAGES
    DUE DATE JUNE 12, 2025

    – ## CASESTUDYANDREQUIREMENT.pdf

    **## CASESTUDYANDREQUIREMENT.pdf**

    Week 6 case study

    Bertha, a 58 – year – old Hispanic female, presents to the primary care clinic to establish care. She states
    that in 1985 she received a blood transfusion after sustained an MVA. She had tested positive for hepatitis
    C virus ( HCV ) in the past, but ignored any advice regarding treatment options. She brings a previous lab
    result with her today that shows :(ALT) level of 85 IU/mL (range 8 – 35 IU/mL). The lab form also states,
    “ HCV antibody is positive by enzyme immunoassay — confirmation is suggested. The patient also
    arrived with diagnosis with exacerbation of A-Fib (pulse 110 beats per mint. and COPD exacerbation as
    well (O2 sat: 87%)

    Past medical h story: Hypertension, dyslipidemia, hepatitis C.

    Family history: Unremarkable

    Social history: She works as a case manager of an HMO and is married with 2 children. Denies use of
    illegal drugs, denies alcohol abuse, and has no tattoos.

    Medications: HCTZ, 12,5 mg daily; Atorvastatin 20 mg daily, Metoprolol Succinate 25 mg and Pro-Air
    HFA 90mcg one puff q 4- 6 hrs as needed x pain.

    Allergies: No known drug or food allergies.

    OBJECTIVE General a ppearance: 58 – year – old female; pleasant, in no acute distress; good eye contact.
    Vital signs: T: 96.8; P: 110; RR: 23; SaO 2 : 87; BP: 150/100. Her weight is 214 lb, and her height is 6.3
    inches.

    HEENT : Negative. Neck: Thyroid nonpalpable. No lymphadenopathy.

    Cardiovascular: A-fib rhythm. irregular and rapid heartbeat.

    Respiratory: Crackles and Wheezing.

    Abdomen: Mild tenderness in right upper quadrant. BS x 4 no bruits. Nondistended, soft. No
    organomegaly. No ascites.

    Neurological: A & O × 4, CN II – XII grossly intact.

    Depression scale: negative. Musculoskeletal: Full ROM. No deformities. Muscle strength is 5/5.

    CRITICAL THINKING

    Which diagnostic or imaging studies should be considered confirm the

    diagnosis?

    What is the most likely differential diagnosis?

    What is your plan of treatment?

    Are there any emergency referrals needed?

    What is first line treatment for AFib in patients with the mentioned comorbidities?

    What is the first line of treatment for COPD exacerbation?

    REQUIREMENTS

    2 PAGES

    NO MORE THAN 10% PLAGIARISM OR STUDENT PAPER SIMILARITY ALLOWED

    MUST BE ORIGINAL AND UNIQUE WORK

    4 REFERENCES SCHOLARLY JOURNALS OR BOOKS NO OLDER THAN 5 YEARS, NO
    BOOKS REFERENCES

    REQUIRED IN-TEXT CITATIONS

    APA 7TH EDITION FORMAT

    CHECK YOUR GRAMMAR AND SPELLING

    DUE DATE JUNE 12 , 2025 NO LATER

    DO YOUR BEST

    MUST BE ORIGINAL EACH WORD IN INDIVIDUAL

    **## CASESTUDYANDREQUIREMENT.pdf**

    Week 6 case study

    Bertha, a 58 – year – old Hispanic female, presents to the primary care clinic to establish care. She states
    that in 1985 she received a blood transfusion after sustained an MVA. She had tested positive for hepatitis
    C virus ( HCV ) in the past, but ignored any advice regarding treatment options. She brings a previous lab
    result with her today that shows :(ALT) level of 85 IU/mL (range 8 – 35 IU/mL). The lab form also states,
    “ HCV antibody is positive by enzyme immunoassay — confirmation is suggested. The patient also
    arrived with diagnosis with exacerbation of A-Fib (pulse 110 beats per mint. and COPD exacerbation as
    well (O2 sat: 87%)

    Past medical h story: Hypertension, dyslipidemia, hepatitis C.

    Family history: Unremarkable

    Social history: She works as a case manager of an HMO and is married with 2 children. Denies use of
    illegal drugs, denies alcohol abuse, and has no tattoos.

    Medications: HCTZ, 12,5 mg daily; Atorvastatin 20 mg daily, Metoprolol Succinate 25 mg and Pro-Air
    HFA 90mcg one puff q 4- 6 hrs as needed x pain.

    Allergies: No known drug or food allergies.

    OBJECTIVE General a ppearance: 58 – year – old female; pleasant, in no acute distress; good eye contact.
    Vital signs: T: 96.8; P: 110; RR: 23; SaO 2 : 87; BP: 150/100. Her weight is 214 lb, and her height is 6.3
    inches.

    HEENT : Negative. Neck: Thyroid nonpalpable. No lymphadenopathy.

    Cardiovascular: A-fib rhythm. irregular and rapid heartbeat.

    Respiratory: Crackles and Wheezing.

    Abdomen: Mild tenderness in right upper quadrant. BS x 4 no bruits. Nondistended, soft. No
    organomegaly. No ascites.

    Neurological: A & O × 4, CN II – XII grossly intact.

    Depression scale: negative. Musculoskeletal: Full ROM. No deformities. Muscle strength is 5/5.

    CRITICAL THINKING

    Which diagnostic or imaging studies should be considered confirm the

    diagnosis?

    What is the most likely differential diagnosis?

    What is your plan of treatment?

    Are there any emergency referrals needed?

    What is first line treatment for AFib in patients with the mentioned comorbidities?

    What is the first line of treatment for COPD exacerbation?

    REQUIREMENTS

    2 PAGES

    NO MORE THAN 10% PLAGIARISM OR STUDENT PAPER SIMILARITY ALLOWED

    MUST BE ORIGINAL AND UNIQUE WORK

    4 REFERENCES SCHOLARLY JOURNALS OR BOOKS NO OLDER THAN 5 YEARS, NO
    BOOKS REFERENCES

    REQUIRED IN-TEXT CITATIONS

    APA 7TH EDITION FORMAT

    CHECK YOUR GRAMMAR AND SPELLING

    DUE DATE JUNE 12 , 2025 NO LATER

    DO YOUR BEST

    MUST BE ORIGINAL EACH WORD IN INDIVIDUAL

  • [Solved] PEDS WK6 DB

    ✓ Verified Academic Solution Available

    Executive Solution Overview

    – ## Week6DBQUESTIONS.docx **## Week6DBQUESTIONS.docx** **Week 6 Discussion Part I** **Table 1** **Differential Diagnosis Pediatric Limp** | | | | | | | | | — | — | — | — | — | — | — | | Complete the table. CC limp | | Condition | Age | Pain (+ or -) | Historical Findings | Clinical Fi…

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    Assignment Prompt & Instructions

    – ## Week6DBQUESTIONS.docx

    **## Week6DBQUESTIONS.docx**

    **Week 6 Discussion Part I**

    **Table 1**

    **Differential Diagnosis Pediatric Limp**

    | | | | | | | |
    | — | — | — | — | — | — | — |
    | Complete the table. CC limp |
    | Condition | Age | Pain (+ or -) | Historical Findings | Clinical Findings | Causative Factors | Management |
    | Developmental Dysplasia of Hip | | | | | | |
    | Leg-length Inequality | | | | | | |
    | Juvenile Arthritis | | | | | | |
    | Slipped capital femoral epiphysis (SCFE) | | | | | | |
    | Legg-Calve-Perthes disease | | | | | | |
    | Transient synovitis | | | | | | |
    | Trauma | | | | | | |
    | Neoplasm | | | | | | |
    | Septic arthritis | | | | | | |
    | Acute hematogenous osteomyelitis | | | | | | |

    **Table 2**

    **Differential Diagnosis Pediatric Headaches**

    | | | |
    | — | — | — |
    | Complete the table. |
    | Common Types | Diagnostic Criteria Based on History | Treatment/Management |
    | Pediatric Migraine Headache | | |
    | Tension Headache | | |
    | Chronic Tension Headache | | |
    | Other Differentials: List 3 additional differentials for headache | Characteristics | Management |
    | 1. | | |
    | 2. | | |
    | 3. | | |

    **Table 3**

    **Musculoskeletal Disorders and Sports-Related Injuries**

    | | | | | | | |
    | — | — | — | — | — | — | — |
    | Complete the table. |
    | | Adolescent Idiopathic Scoliosis | Osgood-Schlatter Disease | Meniscal Tear | Quadriceps Contusion | Sprain of MCL | Osteochondritis dissecans |
    | Description | | | | | | |
    | Screening Test? | | | | | | |
    | How do you perform the screening test? | | | | | | |
    | Imaging? | | | | | | |
    | Treatment Plan | | | | | | |

    Jim is a 17-year-old who was brought into the clinic today for a headache. He reports nausea and an increase in stress from school and after-school activities (basketball practice and debate team). His vital signs are within normal limits and his BMI is 24.

    · What more should you know about Jim?

    · What information in your history and exam would be red flags suggestive of secondary or pathologic headaches

    · What education would you provide for Jim and his parents?

    **## Week6DBQUESTIONS.docx**

    **Week 6 Discussion Part I**

    **Table 1**

    **Differential Diagnosis Pediatric Limp**

    | | | | | | | |
    | — | — | — | — | — | — | — |
    | Complete the table. CC limp |
    | Condition | Age | Pain (+ or -) | Historical Findings | Clinical Findings | Causative Factors | Management |
    | Developmental Dysplasia of Hip | | | | | | |
    | Leg-length Inequality | | | | | | |
    | Juvenile Arthritis | | | | | | |
    | Slipped capital femoral epiphysis (SCFE) | | | | | | |
    | Legg-Calve-Perthes disease | | | | | | |
    | Transient synovitis | | | | | | |
    | Trauma | | | | | | |
    | Neoplasm | | | | | | |
    | Septic arthritis | | | | | | |
    | Acute hematogenous osteomyelitis | | | | | | |

    **Table 2**

    **Differential Diagnosis Pediatric Headaches**

    | | | |
    | — | — | — |
    | Complete the table. |
    | Common Types | Diagnostic Criteria Based on History | Treatment/Management |
    | Pediatric Migraine Headache | | |
    | Tension Headache | | |
    | Chronic Tension Headache | | |
    | Other Differentials: List 3 additional differentials for headache | Characteristics | Management |
    | 1. | | |
    | 2. | | |
    | 3. | | |

    **Table 3**

    **Musculoskeletal Disorders and Sports-Related Injuries**

    | | | | | | | |
    | — | — | — | — | — | — | — |
    | Complete the table. |
    | | Adolescent Idiopathic Scoliosis | Osgood-Schlatter Disease | Meniscal Tear | Quadriceps Contusion | Sprain of MCL | Osteochondritis dissecans |
    | Description | | | | | | |
    | Screening Test? | | | | | | |
    | How do you perform the screening test? | | | | | | |
    | Imaging? | | | | | | |
    | Treatment Plan | | | | | | |

    Jim is a 17-year-old who was brought into the clinic today for a headache. He reports nausea and an increase in stress from school and after-school activities (basketball practice and debate team). His vital signs are within normal limits and his BMI is 24.

    · What more should you know about Jim?

    · What information in your history and exam would be red flags suggestive of secondary or pathologic headaches

    · What education would you provide for Jim and his parents?

  • [Solved] Week 6 DB

    ✓ Verified Academic Solution Available

    Executive Solution Overview

    see attachment – ## Week6DB.pdf **## Week6DB.pdf** Case Scenario 1- Complete the chart and answer the case scenario Kelly is a 19-year-old female who comes to your clinic complaining of severe menstrual pain that is usually worse just prior to and during the first two days of her menses. The pain is…

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    Assignment Prompt & Instructions

    see attachment

    – ## Week6DB.pdf

    **## Week6DB.pdf**

    Case Scenario 1- Complete the chart and answer the case scenario

    Kelly is a 19-year-old female who comes to your clinic complaining of severe menstrual pain that is
    usually worse just prior to and during the first two days of her menses. The pain is sometimes so
    severe that she has fainted. She states that defecation can cause severe pain and she therefore
    frequently becomes constipated. She often must miss work when experiencing the severe pain. Her
    periods are heavy and last seven days with a tapering of the bleeding from days 3 to 7. Her BMI is
    23.9 and her VS are all WNL. She is G0 P0.

    Write a brief SOAP note regarding this patient. Make sure to include your answers to these
    questions in your SOAP note.

    1. Subjective:
    a. What other relevant questions should you ask regarding the HPI?
    b. What other medical history questions should you ask?

    Diagnosis Definition Presentation/

    Sign and
    Symptom

    Management

    Bartholin Cyst

    Squamous
    Carcinoma of the
    Vagina

    Adenocarcinoma
    of the Vagina

    Lichen Sclerosus

    Lichen Planus

    Lichen Simplex
    Chronicus

    Vulvodynia

    c. What other social history questions should you ask?
    d. What other family history questions should you ask?

    2. Objective:
    a. Write a detailed focused physical assessment on this patient.
    b. Explain what test(s) you will order and perform, and discuss your rationale for

    ordering and performing each test.
    3. Assessment/ Diagnosis:

    a. What is your presumptive diagnosis? Why?
    b. Any other diagnosis or differential diagnosis you would like to add?

    4. Plan:
    a. How will you manage this patient? What treatment or medication would you prescribe

    and why?
    b. Explain treatment guidelines and side effects including any possible side effects of

    the medication and treatment(s),
    c. What patient education is important to include for this patient? (Consider including

    pharmacological, supplements, and non pharmacological recommendations and
    education)

    d. What is the follow-up plan of care?
    e. Explain complications that can occur if patient does not comply with treatment

    regimen.

    Please refer to evidence-based guidelines to support your decision-making.

    SOAP NOTE FORMAT

    Subjective

    CC:

    HPI:

    Medications:

    Allergies:

    LMP:

    Gyn/OB history:

    PMH:

    Chronic Illness/ Major trauma:

    Family Hx:

    Social Hx:

    ROS

    – List the body systems and provide answers

    – (Don’t forget to include Gyn ROS)

    – You can include questions here that you’d like to ask the patient

    Objective Data

    General- provide findings

    VS

    List body systems- provide findings

    – (Don’t forget Gyn System)

    – (You can include answers here to questions posed in the prompt)

    Include POCT (Point of Care testing) not labs that you will send to the laboratoryAssessment/

    DiagnosisInclude the ICD10 code

    DDX

    Plan

    Diagnostic tests

    Lab Tests

    Treatment

    Medication

    Referrals

    Education

    Health Maintenance

    Follow up

    Prompt Questions

    (You can include answers here that is asked in the prompt)

    **## Week6DB.pdf**

    Case Scenario 1- Complete the chart and answer the case scenario

    Kelly is a 19-year-old female who comes to your clinic complaining of severe menstrual pain that is
    usually worse just prior to and during the first two days of her menses. The pain is sometimes so
    severe that she has fainted. She states that defecation can cause severe pain and she therefore
    frequently becomes constipated. She often must miss work when experiencing the severe pain. Her
    periods are heavy and last seven days with a tapering of the bleeding from days 3 to 7. Her BMI is
    23.9 and her VS are all WNL. She is G0 P0.

    Write a brief SOAP note regarding this patient. Make sure to include your answers to these
    questions in your SOAP note.

    1. Subjective:
    a. What other relevant questions should you ask regarding the HPI?
    b. What other medical history questions should you ask?

    Diagnosis Definition Presentation/

    Sign and
    Symptom

    Management

    Bartholin Cyst

    Squamous
    Carcinoma of the
    Vagina

    Adenocarcinoma
    of the Vagina

    Lichen Sclerosus

    Lichen Planus

    Lichen Simplex
    Chronicus

    Vulvodynia

    c. What other social history questions should you ask?
    d. What other family history questions should you ask?

    2. Objective:
    a. Write a detailed focused physical assessment on this patient.
    b. Explain what test(s) you will order and perform, and discuss your rationale for

    ordering and performing each test.
    3. Assessment/ Diagnosis:

    a. What is your presumptive diagnosis? Why?
    b. Any other diagnosis or differential diagnosis you would like to add?

    4. Plan:
    a. How will you manage this patient? What treatment or medication would you prescribe

    and why?
    b. Explain treatment guidelines and side effects including any possible side effects of

    the medication and treatment(s),
    c. What patient education is important to include for this patient? (Consider including

    pharmacological, supplements, and non pharmacological recommendations and
    education)

    d. What is the follow-up plan of care?
    e. Explain complications that can occur if patient does not comply with treatment

    regimen.

    Please refer to evidence-based guidelines to support your decision-making.

    SOAP NOTE FORMAT

    Subjective

    CC:

    HPI:

    Medications:

    Allergies:

    LMP:

    Gyn/OB history:

    PMH:

    Chronic Illness/ Major trauma:

    Family Hx:

    Social Hx:

    ROS

    – List the body systems and provide answers

    – (Don’t forget to include Gyn ROS)

    – You can include questions here that you’d like to ask the patient

    Objective Data

    General- provide findings

    VS

    List body systems- provide findings

    – (Don’t forget Gyn System)

    – (You can include answers here to questions posed in the prompt)

    Include POCT (Point of Care testing) not labs that you will send to the laboratoryAssessment/

    DiagnosisInclude the ICD10 code

    DDX

    Plan

    Diagnostic tests

    Lab Tests

    Treatment

    Medication

    Referrals

    Education

    Health Maintenance

    Follow up

    Prompt Questions

    (You can include answers here that is asked in the prompt)

  • [Solved] wk6 focused peds soap note

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    Executive Solution Overview

    – ## wellchildsoapnotetemplate.docx **## wellchildsoapnotetemplate.docx** **Well-child SOAP Note Format** _Demographic Data_ · Age, and gender (must be HIPAA compliant) _Subjective_ · ___-day/week old infant/child accompanied by ___________ and here for a routine well-child/baby check …

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    Assignment Prompt & Instructions

    – ## wellchildsoapnotetemplate.docx

    **## wellchildsoapnotetemplate.docx**

    **Well-child SOAP Note Format**

    _Demographic Data_

    · Age, and gender (must be HIPAA compliant)

    _Subjective_

    · ___-day/week old infant/child accompanied by ___________ and here for a routine well-child/baby check (and vaccines). Any parental concerns/ questions today?

    · Interval Events/History:

    · Nutrition:

    · Elimination:

    · Sleep:

    · Medications:

    · Allergies:

    · Past Medical

    ·

    · Pregnancy and delivery?

    · Surgeries, hospitalizations, or serious illnesses to date?

    · Immunizations?

    · Development: (describe as applicable to age)

    ·

    · Gross motor:

    ·

    · Fine motor:

    · Cognitive:

    · Social/Emotional:

    · Communication:

    · Social History:

    · Smoking in the home?

    · Family life/structure/dynamics? Primary caregivers?

    · Stressors?

    ·  Family History:

    _Objective_ _(Should be a thorough head to toe assessment)_

    · Vital Signs/growth measurements (weight, length, head circumference, BMI, BP, HR, etc. if applicable)

    ·

    · Physical findings listed by body systems, not paragraph form.

    · Highlight abnormal findings

    · Growth Chart Percentages: if applicable

    · Labs/Studies: if applicable

    _Assessment_

    · Well-child visit ICD10 code(s)

    _Plan_

    · Vaccines today:

    · Anticipatory guidance (discussed or covered in the visit)?

    · Health Maintenance

    · Return precautions?

    **## wellchildsoapnotetemplate.docx**

    **Well-child SOAP Note Format**

    _Demographic Data_

    · Age, and gender (must be HIPAA compliant)

    _Subjective_

    · ___-day/week old infant/child accompanied by ___________ and here for a routine well-child/baby check (and vaccines). Any parental concerns/ questions today?

    · Interval Events/History:

    · Nutrition:

    · Elimination:

    · Sleep:

    · Medications:

    · Allergies:

    · Past Medical

    ·

    · Pregnancy and delivery?

    · Surgeries, hospitalizations, or serious illnesses to date?

    · Immunizations?

    · Development: (describe as applicable to age)

    ·

    · Gross motor:

    ·

    · Fine motor:

    · Cognitive:

    · Social/Emotional:

    · Communication:

    · Social History:

    · Smoking in the home?

    · Family life/structure/dynamics? Primary caregivers?

    · Stressors?

    ·  Family History:

    _Objective_ _(Should be a thorough head to toe assessment)_

    · Vital Signs/growth measurements (weight, length, head circumference, BMI, BP, HR, etc. if applicable)

    ·

    · Physical findings listed by body systems, not paragraph form.

    · Highlight abnormal findings

    · Growth Chart Percentages: if applicable

    · Labs/Studies: if applicable

    _Assessment_

    · Well-child visit ICD10 code(s)

    _Plan_

    · Vaccines today:

    · Anticipatory guidance (discussed or covered in the visit)?

    · Health Maintenance

    · Return precautions?