Hypertension Case StudyC.D is a 55-year-old African American male
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Hypertension Case Study C.D is a 55-year-old African American male who presents to his primary care provider with a 2-day history of a headache and chest pressure. PMH Allergic RhinitisDepressionHypothyroidism Family History Father died at age 49 from AMI: had HTNMother has DM and HTNBrother died at age 20 from complications of CFTwo younger sisters are A&W Social History The patient has been married for 25 years and lives with his wife and two children. The patient is an air traffic controller at the local airport. He has smoked a pack of cigarettes a day for the past 15 years. He drinks several beers every evening after work to relax. He does not pay particular attention to sodium, fat, or carbohydrates in the foods he eats. He admits to “salting almost everything he eats, sometimes even before tasting it.” He denies ever having dieted or exercised. Medications Zyrtec 10 mg daily Allergies Penicillin ROS States that his overall health has been fair to good during the past year.Weight has increased by approximately 30 pounds in the last 12 months.States he has been having some occasional chest pressure and headaches for the past 2 days. Shortness of breath at rest, headaches, nocturia, nosebleeds, and hemoptysis.Reports some shortness of breath with activity, especially when climbing stairs and that breathing difficulties are getting worse.Denies any nausea, vomiting, diarrhea, or blood in stool.Self treats for occasional right knee pain with OTC Ibuprofen.Denies any genitourinary symptoms. Vital Signs B/P 190/120, HR 73, RR 18, T. 98.8 F., Ht 6’1”, Wt 240 lbs. HEENT TMs intact and clear throughoutNo nasal drainageNo exudates or erythema in oropharynxPERRLAFunduscopy reveals mild arteriolar narrowing without nicking, hemorrhages, exudates, or papilledema Neck Supple without masses or bruitsThyroid normalNo lymphadenopathy Lungs Mild basilar crackles bilaterallyNo wheezes Heart RRRNo murmurs or rubs Abdomen Soft and non-distendedNo masses, bruits, or organomegalyNormal bowel sounds Ext Moves all extremities well Neuro No sensory or motor abnormalitiesCN’s II-XII intactDTR’s = 2+Muscle tone=5/5 throughout What you should do: Develop an evidence-based management plan.Include any pertinent diagnostics.Describe the patient education plan.Include cultural and lifespan considerations.Provide information on health promotion or health care maintenance needs.Describe the follow-up and referral for this patient.Prepare a 3–5-page paper (not including the title page or reference page). Assignment Requirements: Before finalizing your work, you should:be sure to read the Assignment description carefully (as displayed above); consult the Grading Rubric to make sure you have included everything necessary; andutilize spelling and grammar check to minimize errors.Your writing Assignment should:follow the conventions of Standard English (correct grammar, punctuation, etc.);be well ordered , logical , and unified , as well as original and insightfu ...
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Assignment DetailsThis Assignment will assess your ability t.docx
Assignment Details
This Assignment will assess your ability to evaluate subjective and objective information in order to arrive at an appropriate diagnosis and treatment plan for the patient.
Hypertension Case Study
C.D is a 55-year-old African American male who presents to his primary care provider with a 2-day history of a headache and chest pressure.
PMH
Allergic Rhinitis
Depression
Hypothyroidism
Family History
Father died at age 49 from AMI: had HTN
Mother has DM and HTN
Brother died at age 20 from complications of CF
Two younger sisters are A&W
Social History
The patient has been married for 25 years and lives with his wife and two children. The patient is an air traffic controller at the local airport. He has smoked a pack of cigarettes a day for the past 15 years. He drinks several beers every evening after work to relax. He does not pay particular attention to sodium, fat, or carbohydrates in the foods he eats. He admits to “salting almost everything he eats, sometimes even before tasting it.” He denies ever having dieted or exercised.
Medications
Zyrtec 10 mg daily
Allergies
Penicillin
ROS
States that his overall health has been fair to good during the past year.
Weight has increased by approximately 30 pounds in the last 12 months.
States he has been having some occasional chest pressure and headaches for the past 2 days. Shortness of breath at rest, headaches, nocturia, nosebleeds, and hemoptysis.
Reports some shortness of breath with activity, especially when climbing stairs and that breathing difficulties are getting worse.
Denies any nausea, vomiting, diarrhea, or blood in stool.
Self treats for occasional right knee pain with OTC Ibuprofen.
Denies any genitourinary symptoms.
Vital Signs
B/P 190/120, HR 73, RR 18, T. 98.8 F., Ht 6’1”, Wt 240 lbs.
HEENT
TMs intact and clear throughout
No nasal drainage
No exudates or erythema in oropharynx
PERRLA
Funduscopy reveals mild arteriolar narrowing without nicking, hemorrhages, exudates, or papilledema
Neck
Supple without masses or bruits
Thyroid normal
No lymphadenopathy
Lungs
Mild basilar crackles bilaterally
No wheezes
Heart
RRR
No murmurs or rubs
Abdomen
Soft and non-distended
No masses, bruits, or organomegaly
Normal bowel sounds
Ext
Moves all extremities well
Neuro
No sensory or motor abnormalities
CN’s II-XII intact
DTR’s = 2+
Muscle tone=5/5 throughout
What you should do:
Develop an evidence-based management plan.
Include any pertinent diagnostics.
Describe the patient education plan.
Include cultural and lifespan considerations.
Provide information on health promotion or health care maintenance needs.
Describe the follow-up and referral for this patient.
Prepare a 3–5-page paper (not including the title page or reference page).
Assignment Requirements:
Before finalizing your work, you should:
be sure to
read the Assignment description carefully
(as displayed above);
consult the Grading Rubric
to make sure .
This Assignment will assess your ability to evaluate subjective .docx
This Assignment will assess your ability to evaluate subjective and objective information in order to arrive at an appropriate diagnosis and treatment plan for the patient.
Hypertension Case Study
C.D is a 55-year-old African American male who presents to his primary care provider with a 2-day history of a headache and chest pressure.
PMH
Allergic Rhinitis
Depression
Hypothyroidism
Family History
Father died at age 49 from AMI: had HTN
Mother has DM and HTN
Brother died at age 20 from complications of CF
Two younger sisters are A&W
Social History
The patient has been married for 25 years and lives with his wife and two children. The patient is an air traffic controller at the local airport. He has smoked a pack of cigarettes a day for the past 15 years. He drinks several beers every evening after work to relax. He does not pay particular attention to sodium, fat, or carbohydrates in the foods he eats. He admits to “salting almost everything he eats, sometimes even before tasting it.” He denies ever having dieted or exercised.
Medications
Zyrtec 10 mg daily
Allergies
Penicillin
ROS
States that his overall health has been fair to good during the past year.
Weight has increased by approximately 30 pounds in the last 12 months.
States he has been having some occasional chest pressure and headaches for the past 2 days. Shortness of breath at rest, headaches, nocturia, nosebleeds, and hemoptysis.
Reports some shortness of breath with activity, especially when climbing stairs and that breathing difficulties are getting worse.
Denies any nausea, vomiting, diarrhea, or blood in stool.
Self treats for occasional right knee pain with OTC Ibuprofen.
Denies any genitourinary symptoms.
Vital Signs
B/P 190/120, HR 73, RR 18, T. 98.8 F., Ht 6’1”, Wt 240 lbs.
HEENT
TMs intact and clear throughout
No nasal drainage
No exudates or erythema in oropharynx
PERRLA
Funduscopy reveals mild arteriolar narrowing without nicking, hemorrhages, exudates, or papilledema
Neck
Supple without masses or bruits
Thyroid normal
No lymphadenopathy
Lungs
Mild basilar crackles bilaterally
No wheezes
Heart
RRR
No murmurs or rubs
Abdomen
Soft and non-distended
No masses, bruits, or organomegaly
Normal bowel sounds
Ext
Moves all extremities well
Neuro
No sensory or motor abnormalities
CN’s II-XII intact
DTR’s = 2+
Muscle tone=5/5 throughout
What you should do:
Develop an evidence-based management plan.
Include any pertinent diagnostics.
Describe the patient education plan.
Include cultural and lifespan considerations.
Provide information on health promotion or health care maintenance needs.
Describe the follow-up and referral for this patient.
Prepare a 3–5-page paper (not including the title page or reference page).
Your writing Assignment should:
follow the conventions of
Standard English
(correct grammar, punctuation, etc.);
be
well ordered
,
logical
, and
unified
, as well as
original and insightful
;
displ.
Soap note Reflux Disease.docx
This soap note summarizes the assessment and plan of care for a 65-year-old male patient presenting with new onset headaches over the past two weeks. On examination, the patient was found to have elevated blood pressure readings of 159/100, 158/98 and 160/100 mmHg. Based on his symptoms and blood pressure readings, the patient was diagnosed with essential (primary) hypertension. The treatment plan included starting hydrochlorothiazide 25 mg daily, as well as lifestyle modifications like diet, exercise and stress reduction. Follow up with his primary care provider in one week was arranged to monitor his blood pressure control and medication response.
SOAP NOTE SAMPLE FORMAT FOR MRCName LPDateTime 1315.docx
SOAP NOTE SAMPLE FORMAT FOR MRC
Name: LP
Date:
Time: 1315
Age: 30
Sex: F
SUBJECTIVE
CC:
“I am having vaginal itching and pain in my lower abdomen.”
HPI:
Pt is a 30y/o AA female, who is a new patient that has recently moved to Miami. She seeks treatment today after unsuccessful self-treatment of vaginal itching, burning upon urination, and lower abdominal pain. She is concerned for the presence of a vaginal or bladder infection, or an STD. Pt denies fever. She reports the itching and burning with urination has been present for 3 weeks, and the abdominal pain has been intermittent since months ago. Pt has tried OTC products for the itching, including Monistat and Vagisil. She denies any other urinary symptoms, including urgency or frequency. She describes the abdominal pain as either sharp or dull. The pain level goes as high as 8 out of 10 at times. 200mg of PO Advil PRN reduces the pain to a 7/10. Pt denies any aggravating factors for the pain. Pt reports that she did start her menstrual cycle this morning, but denies any other discharge other that light bleeding beginning today. Pt denies douching or the use of any vaginal irritants. She reports that she is in a stable sexual relationship, and denies any new sexual partners in the last 90 days. She denies any recent or historic known exposure to STDs. She reports the use of condoms with every coital experience, as well as this being her only form of contraceptive. She reports normal monthly menstrual cycles that last 3-4 days. She reports dysmenorrhea, which she also takes Advil for. She reports her last PAP smear was in 7/2016, was normal, and reports never having an abnormal PAP smear result. Pt denies any hx of pregnancies. Other medical hx includes GERD. She reports that she has an Rx for Protonix, but she does not take it every day. Her family hx includes the presence of DM and HTN.
Current Medications:
Protonix 40mg PO Daily for GERD
MTV OTC PO Daily
Advil 200mg OTC PO PRN for pain
PMHx:
Allergies:
NKA & NKDA
Medication Intolerances:
Denies
Chronic Illnesses/Major traumas
GERD
Hospitalizations/Surgeries
Denies
Family History
Father- DM & HTN; Mother- HTN; Older sister- DM & HTN; Maternal and paternal grandparents without known medical issues; 1 brother and 3 other sisters without known medical issues; No children.
Social History
Lives alone. Currently in a stable sexual relationship with one man. Works for DEFACS. Reports occasional alcohol use, but denies tobacco or illicit drug use.
ROS
General
Denies weight change, fatigue, fever, night sweats
Cardiovascular
Denies chest pain and edema. Reports rare palpitations that are relieved by drinking water
Skin
Denies any wounds, rashes, bruising, bleeding or skin discolorations, any changes in lesions
Respiratory
Denies cough. Reports dyspnea that accompanies the rare palpitations and is also relieved by drinking water
Eyes
Denies corrective lenses, blurring, visual changes of an.
PATIENT INFORMATIONName Mr. W.S.Age 65-year-oldSex Male.docx
PATIENT INFORMATION
Name: Mr. W.S.
Age: 65-year-old
Sex: Male
Source: Patient
Allergies: None
Current Medications: Atorvastatin tab 20 mg, 1-tab PO at bedtime
PMH: Hypercholesterolemia
Immunizations: Influenza last 2018-year, tetanus, and hepatitis A and B 4 years ago.
Surgical History: Appendectomy 47 years ago.
Family History: Father- died 81 does not report information
Mother-alive, 88 years old, Diabetes Mellitus, HTN
Daughter-alive, 34 years old, healthy
Social Hx: No smoking history or illicit drug use, occasional alcoholic beverage consumption on social celebrations. Retired, widow, he lives alone.
SUBJECTIVE:
Chief complain: “headaches” that started two weeks ago
Symptom analysis/HPI:
The patient is 65 years old male who complaining of episodes of headaches and on 3 different occasions blood pressure was measured, which was high (159/100, 158/98 and 160/100 respectively). Patient noticed the problem started two weeks ago and sometimes it is accompanied by dizziness. He states that he has been under stress in his workplace for the last month.
Patient denies chest pain, palpitation, shortness of breath, nausea or vomiting.
ROS:
CONSTITUTIONAL: Denies fever or chills. Denies weakness or weight loss. NEUROLOGIC: Headache and dizzeness as describe above. Denies changes in LOC. Denies history of tremors or seizures.
HEENT: HEAD: Denies any head injury, or change in LOC. Eyes: Denies any changes in vision, diplopia or blurred vision. Ear: Denies pain in the ears. Denies loss of hearing or drainage. Nose: Denies nasal drainage, congestion. THROAT: Denies throat or neck pain, hoarseness, difficulty swallowing.
Respiratory: Patient denies shortness of breath, cough or hemoptysis.
Cardiovascular: No chest pain, tachycardia. No orthopnea or paroxysmal nocturnal
dyspnea.
Gastrointestinal: Denies abdominal pain or discomfort. Denies flatulence, nausea, vomiting or
diarrhea.
Genitourinary: Denies hematuria, dysuria or change in urinary frequency. Denies difficulty starting/stopping stream of urine or incontinence.
MUSCULOSKELETAL: Denies falls or pain. Denies hearing a clicking or snapping sound.
Skin: No change of coloration such as cyanosis or jaundice, no rashes or pruritus.
Objective Data
CONSTITUTIONAL: Vital signs: Temperature: 98.5 °F, Pulse: 87, BP: 159/92 mmhg, RR 20, PO2-98% on room air, Ht- 6’4”, Wt 200 lb, BMI 25. Report pain 0/10.
General appearance: The patient is alert and oriented x 3. No acute distress noted. NEUROLOGIC: Alert, CNII-XII grossly intact, oriented to person, place, and time. Sensation intact to bilateral upper and lower extremities. Bilateral UE/LE strength 5/5.
HEENT: Head: Normocephalic, atraumatic, symmetric, non-tender. Maxillary sinuses no tenderness. Eyes: No conjunctival injection, no icterus, visual acuity and extraocular eye movements intact. No nystagmus noted. Ears: Bilateral canals patent without erythema, edema, or exudate. Bilateral tympanic membrane.
Mr. Brown is a 65 year old African American male who presents to.docx
Mr. Brown is a 65 year old African American male who presents to the clinic for a physical exam. He has not seen a provider in over 10 years and is here at the insistence of his wife. Lately he has been experiencing more “heartburn after I eat” but “nothing that I can’t live with.” Mr. Brown reports taking over the counter Pepcid about 2-3 times a week with some relief. Other than the reflux type symptoms, he denies any other medical issues. He just needed to get a checkup.
Allergies: Strawberries, NKDA
Current medications: Pepcid OTC as needed
PMH: GERD,
PSH: Tonsillectomy, appendectomy
Social: Tobacco: 1 PPD, Alcohol: 2-3 drinks every 3-4 days, Denies illegal drug use. He works fulltime at Lowe’s, does report some heavy lifting. He is married with 2 grown sons and 5 grandchildren. In a monogamous relationship. He is active, coaching little league football.
Immunizations: unsure
Family: Father: died at 72 of MI, Mother: died at 60 of breast cancer
ROS:
Constitional:
HEENT: Denies any headache, nasal congestion, ear pain
Cardiovascular: Denies chest pain
Respiratory: Denies any SOB, DOE, orthnopenia
GI: Reports some burning pain at times, feels like heartburn.
GU: Denies any painful urination, urgency, hesitancy
Musculoskeletal: Reports some knee pain with bending, walking long distances. Denies any swelling or redness
Neurological: Denies
Psychiatric: Denies suidicial ideations, depression. Does report difficulty falling asleep
Endocrine: Reports he has lost about 10 pounds over the last few months.
Hematologic/ Lymphatic: Denies any bruising
OBJECTIVE:
Vital signs: Ht: 70, Wt: 265, BP 178/94, HR 92, Resp: 16, SaO2: 95%
Constitutional: Well developed, obese male
HEENT: Oropharynx pink, moist, no lesions or exudate. Tonsils 1+ bilaterally. Teeth in good repair, no cavities noted. Tongue smooth, pink, no lesions, protrudes in midline. Neck supple. No cervical lymphadenopathy or tenderness noted. Thyroid midline, small and firm without palpable masses
Cardiovascular: RRR, No murmurs or rubs noted. No peripheral edema noted
Respiratory: Faint expiratory wheezes noted bilaterally, cleared after coughing.
GI: Abdomen round, soft, with bowel sounds noted in all four quadrants. No organo-megaly noted.
GU: Deferred
Musceloskeletal: Crepatus noted bil knees, no warmth or redness noted.
Integrementary: Skin warm and dry, No rashes noted
Neuro: Follows commands without difficulty
Working with your group, utilize the above case study a, develop a Voice Over PowerPoint presentation for your patient covering the problems identified in the case study and content in Unit 3 of Edelman, Kudzama, & Mandle (2018). Include the following:
2-Health Education
3-Complementary and Alternative Strategies
.
Mrs. Jones is a 32 year old Caucasian female who presents for fo.docx
A 32-year-old woman presents for follow-up for gestational diabetes. She was diagnosed with gestational diabetes during her first pregnancy 3 months ago but has not checked her blood glucose since leaving the hospital due to being busy. She has a strong family history of diabetes and was told to monitor her blood glucose after weaning from breastfeeding. On examination, she is overweight but otherwise healthy. She reports increased fatigue and difficulty sleeping.
Case Study Ankylosing Spondylitis.docx
This case study involves a 65-year-old male presenting with headaches and high blood pressure readings over the past two weeks. On examination, his blood pressure was elevated at 159/92 mmHg. The assessment is essential (primary) hypertension, given his symptoms and blood pressure levels. The plan is to initiate pharmacological treatment with hydrochlorothiazide and provide lifestyle counseling. Follow up with his primary care provider in a week is recommended to monitor his blood pressure and medication management.
Recommended
Assignment DetailsThis Assignment will assess your ability t.docx
Assignment Details
This Assignment will assess your ability to evaluate subjective and objective information in order to arrive at an appropriate diagnosis and treatment plan for the patient.
Hypertension Case Study
C.D is a 55-year-old African American male who presents to his primary care provider with a 2-day history of a headache and chest pressure.
PMH
Allergic Rhinitis
Depression
Hypothyroidism
Family History
Father died at age 49 from AMI: had HTN
Mother has DM and HTN
Brother died at age 20 from complications of CF
Two younger sisters are A&W
Social History
The patient has been married for 25 years and lives with his wife and two children. The patient is an air traffic controller at the local airport. He has smoked a pack of cigarettes a day for the past 15 years. He drinks several beers every evening after work to relax. He does not pay particular attention to sodium, fat, or carbohydrates in the foods he eats. He admits to “salting almost everything he eats, sometimes even before tasting it.” He denies ever having dieted or exercised.
Medications
Zyrtec 10 mg daily
Allergies
Penicillin
ROS
States that his overall health has been fair to good during the past year.
Weight has increased by approximately 30 pounds in the last 12 months.
States he has been having some occasional chest pressure and headaches for the past 2 days. Shortness of breath at rest, headaches, nocturia, nosebleeds, and hemoptysis.
Reports some shortness of breath with activity, especially when climbing stairs and that breathing difficulties are getting worse.
Denies any nausea, vomiting, diarrhea, or blood in stool.
Self treats for occasional right knee pain with OTC Ibuprofen.
Denies any genitourinary symptoms.
Vital Signs
B/P 190/120, HR 73, RR 18, T. 98.8 F., Ht 6’1”, Wt 240 lbs.
HEENT
TMs intact and clear throughout
No nasal drainage
No exudates or erythema in oropharynx
PERRLA
Funduscopy reveals mild arteriolar narrowing without nicking, hemorrhages, exudates, or papilledema
Neck
Supple without masses or bruits
Thyroid normal
No lymphadenopathy
Lungs
Mild basilar crackles bilaterally
No wheezes
Heart
RRR
No murmurs or rubs
Abdomen
Soft and non-distended
No masses, bruits, or organomegaly
Normal bowel sounds
Ext
Moves all extremities well
Neuro
No sensory or motor abnormalities
CN’s II-XII intact
DTR’s = 2+
Muscle tone=5/5 throughout
What you should do:
Develop an evidence-based management plan.
Include any pertinent diagnostics.
Describe the patient education plan.
Include cultural and lifespan considerations.
Provide information on health promotion or health care maintenance needs.
Describe the follow-up and referral for this patient.
Prepare a 3–5-page paper (not including the title page or reference page).
Assignment Requirements:
Before finalizing your work, you should:
be sure to
read the Assignment description carefully
(as displayed above);
consult the Grading Rubric
to make sure .
This Assignment will assess your ability to evaluate subjective .docx
This Assignment will assess your ability to evaluate subjective and objective information in order to arrive at an appropriate diagnosis and treatment plan for the patient.
Hypertension Case Study
C.D is a 55-year-old African American male who presents to his primary care provider with a 2-day history of a headache and chest pressure.
PMH
Allergic Rhinitis
Depression
Hypothyroidism
Family History
Father died at age 49 from AMI: had HTN
Mother has DM and HTN
Brother died at age 20 from complications of CF
Two younger sisters are A&W
Social History
The patient has been married for 25 years and lives with his wife and two children. The patient is an air traffic controller at the local airport. He has smoked a pack of cigarettes a day for the past 15 years. He drinks several beers every evening after work to relax. He does not pay particular attention to sodium, fat, or carbohydrates in the foods he eats. He admits to “salting almost everything he eats, sometimes even before tasting it.” He denies ever having dieted or exercised.
Medications
Zyrtec 10 mg daily
Allergies
Penicillin
ROS
States that his overall health has been fair to good during the past year.
Weight has increased by approximately 30 pounds in the last 12 months.
States he has been having some occasional chest pressure and headaches for the past 2 days. Shortness of breath at rest, headaches, nocturia, nosebleeds, and hemoptysis.
Reports some shortness of breath with activity, especially when climbing stairs and that breathing difficulties are getting worse.
Denies any nausea, vomiting, diarrhea, or blood in stool.
Self treats for occasional right knee pain with OTC Ibuprofen.
Denies any genitourinary symptoms.
Vital Signs
B/P 190/120, HR 73, RR 18, T. 98.8 F., Ht 6’1”, Wt 240 lbs.
HEENT
TMs intact and clear throughout
No nasal drainage
No exudates or erythema in oropharynx
PERRLA
Funduscopy reveals mild arteriolar narrowing without nicking, hemorrhages, exudates, or papilledema
Neck
Supple without masses or bruits
Thyroid normal
No lymphadenopathy
Lungs
Mild basilar crackles bilaterally
No wheezes
Heart
RRR
No murmurs or rubs
Abdomen
Soft and non-distended
No masses, bruits, or organomegaly
Normal bowel sounds
Ext
Moves all extremities well
Neuro
No sensory or motor abnormalities
CN’s II-XII intact
DTR’s = 2+
Muscle tone=5/5 throughout
What you should do:
Develop an evidence-based management plan.
Include any pertinent diagnostics.
Describe the patient education plan.
Include cultural and lifespan considerations.
Provide information on health promotion or health care maintenance needs.
Describe the follow-up and referral for this patient.
Prepare a 3–5-page paper (not including the title page or reference page).
Your writing Assignment should:
follow the conventions of
Standard English
(correct grammar, punctuation, etc.);
be
well ordered
,
logical
, and
unified
, as well as
original and insightful
;
displ.
Soap note Reflux Disease.docx
This soap note summarizes the assessment and plan of care for a 65-year-old male patient presenting with new onset headaches over the past two weeks. On examination, the patient was found to have elevated blood pressure readings of 159/100, 158/98 and 160/100 mmHg. Based on his symptoms and blood pressure readings, the patient was diagnosed with essential (primary) hypertension. The treatment plan included starting hydrochlorothiazide 25 mg daily, as well as lifestyle modifications like diet, exercise and stress reduction. Follow up with his primary care provider in one week was arranged to monitor his blood pressure control and medication response.
SOAP NOTE SAMPLE FORMAT FOR MRCName LPDateTime 1315.docx
SOAP NOTE SAMPLE FORMAT FOR MRC
Name: LP
Date:
Time: 1315
Age: 30
Sex: F
SUBJECTIVE
CC:
“I am having vaginal itching and pain in my lower abdomen.”
HPI:
Pt is a 30y/o AA female, who is a new patient that has recently moved to Miami. She seeks treatment today after unsuccessful self-treatment of vaginal itching, burning upon urination, and lower abdominal pain. She is concerned for the presence of a vaginal or bladder infection, or an STD. Pt denies fever. She reports the itching and burning with urination has been present for 3 weeks, and the abdominal pain has been intermittent since months ago. Pt has tried OTC products for the itching, including Monistat and Vagisil. She denies any other urinary symptoms, including urgency or frequency. She describes the abdominal pain as either sharp or dull. The pain level goes as high as 8 out of 10 at times. 200mg of PO Advil PRN reduces the pain to a 7/10. Pt denies any aggravating factors for the pain. Pt reports that she did start her menstrual cycle this morning, but denies any other discharge other that light bleeding beginning today. Pt denies douching or the use of any vaginal irritants. She reports that she is in a stable sexual relationship, and denies any new sexual partners in the last 90 days. She denies any recent or historic known exposure to STDs. She reports the use of condoms with every coital experience, as well as this being her only form of contraceptive. She reports normal monthly menstrual cycles that last 3-4 days. She reports dysmenorrhea, which she also takes Advil for. She reports her last PAP smear was in 7/2016, was normal, and reports never having an abnormal PAP smear result. Pt denies any hx of pregnancies. Other medical hx includes GERD. She reports that she has an Rx for Protonix, but she does not take it every day. Her family hx includes the presence of DM and HTN.
Current Medications:
Protonix 40mg PO Daily for GERD
MTV OTC PO Daily
Advil 200mg OTC PO PRN for pain
PMHx:
Allergies:
NKA & NKDA
Medication Intolerances:
Denies
Chronic Illnesses/Major traumas
GERD
Hospitalizations/Surgeries
Denies
Family History
Father- DM & HTN; Mother- HTN; Older sister- DM & HTN; Maternal and paternal grandparents without known medical issues; 1 brother and 3 other sisters without known medical issues; No children.
Social History
Lives alone. Currently in a stable sexual relationship with one man. Works for DEFACS. Reports occasional alcohol use, but denies tobacco or illicit drug use.
ROS
General
Denies weight change, fatigue, fever, night sweats
Cardiovascular
Denies chest pain and edema. Reports rare palpitations that are relieved by drinking water
Skin
Denies any wounds, rashes, bruising, bleeding or skin discolorations, any changes in lesions
Respiratory
Denies cough. Reports dyspnea that accompanies the rare palpitations and is also relieved by drinking water
Eyes
Denies corrective lenses, blurring, visual changes of an.
PATIENT INFORMATIONName Mr. W.S.Age 65-year-oldSex Male.docx
PATIENT INFORMATION
Name: Mr. W.S.
Age: 65-year-old
Sex: Male
Source: Patient
Allergies: None
Current Medications: Atorvastatin tab 20 mg, 1-tab PO at bedtime
PMH: Hypercholesterolemia
Immunizations: Influenza last 2018-year, tetanus, and hepatitis A and B 4 years ago.
Surgical History: Appendectomy 47 years ago.
Family History: Father- died 81 does not report information
Mother-alive, 88 years old, Diabetes Mellitus, HTN
Daughter-alive, 34 years old, healthy
Social Hx: No smoking history or illicit drug use, occasional alcoholic beverage consumption on social celebrations. Retired, widow, he lives alone.
SUBJECTIVE:
Chief complain: “headaches” that started two weeks ago
Symptom analysis/HPI:
The patient is 65 years old male who complaining of episodes of headaches and on 3 different occasions blood pressure was measured, which was high (159/100, 158/98 and 160/100 respectively). Patient noticed the problem started two weeks ago and sometimes it is accompanied by dizziness. He states that he has been under stress in his workplace for the last month.
Patient denies chest pain, palpitation, shortness of breath, nausea or vomiting.
ROS:
CONSTITUTIONAL: Denies fever or chills. Denies weakness or weight loss. NEUROLOGIC: Headache and dizzeness as describe above. Denies changes in LOC. Denies history of tremors or seizures.
HEENT: HEAD: Denies any head injury, or change in LOC. Eyes: Denies any changes in vision, diplopia or blurred vision. Ear: Denies pain in the ears. Denies loss of hearing or drainage. Nose: Denies nasal drainage, congestion. THROAT: Denies throat or neck pain, hoarseness, difficulty swallowing.
Respiratory: Patient denies shortness of breath, cough or hemoptysis.
Cardiovascular: No chest pain, tachycardia. No orthopnea or paroxysmal nocturnal
dyspnea.
Gastrointestinal: Denies abdominal pain or discomfort. Denies flatulence, nausea, vomiting or
diarrhea.
Genitourinary: Denies hematuria, dysuria or change in urinary frequency. Denies difficulty starting/stopping stream of urine or incontinence.
MUSCULOSKELETAL: Denies falls or pain. Denies hearing a clicking or snapping sound.
Skin: No change of coloration such as cyanosis or jaundice, no rashes or pruritus.
Objective Data
CONSTITUTIONAL: Vital signs: Temperature: 98.5 °F, Pulse: 87, BP: 159/92 mmhg, RR 20, PO2-98% on room air, Ht- 6’4”, Wt 200 lb, BMI 25. Report pain 0/10.
General appearance: The patient is alert and oriented x 3. No acute distress noted. NEUROLOGIC: Alert, CNII-XII grossly intact, oriented to person, place, and time. Sensation intact to bilateral upper and lower extremities. Bilateral UE/LE strength 5/5.
HEENT: Head: Normocephalic, atraumatic, symmetric, non-tender. Maxillary sinuses no tenderness. Eyes: No conjunctival injection, no icterus, visual acuity and extraocular eye movements intact. No nystagmus noted. Ears: Bilateral canals patent without erythema, edema, or exudate. Bilateral tympanic membrane.
Mr. Brown is a 65 year old African American male who presents to.docx
Mr. Brown is a 65 year old African American male who presents to the clinic for a physical exam. He has not seen a provider in over 10 years and is here at the insistence of his wife. Lately he has been experiencing more “heartburn after I eat” but “nothing that I can’t live with.” Mr. Brown reports taking over the counter Pepcid about 2-3 times a week with some relief. Other than the reflux type symptoms, he denies any other medical issues. He just needed to get a checkup.
Allergies: Strawberries, NKDA
Current medications: Pepcid OTC as needed
PMH: GERD,
PSH: Tonsillectomy, appendectomy
Social: Tobacco: 1 PPD, Alcohol: 2-3 drinks every 3-4 days, Denies illegal drug use. He works fulltime at Lowe’s, does report some heavy lifting. He is married with 2 grown sons and 5 grandchildren. In a monogamous relationship. He is active, coaching little league football.
Immunizations: unsure
Family: Father: died at 72 of MI, Mother: died at 60 of breast cancer
ROS:
Constitional:
HEENT: Denies any headache, nasal congestion, ear pain
Cardiovascular: Denies chest pain
Respiratory: Denies any SOB, DOE, orthnopenia
GI: Reports some burning pain at times, feels like heartburn.
GU: Denies any painful urination, urgency, hesitancy
Musculoskeletal: Reports some knee pain with bending, walking long distances. Denies any swelling or redness
Neurological: Denies
Psychiatric: Denies suidicial ideations, depression. Does report difficulty falling asleep
Endocrine: Reports he has lost about 10 pounds over the last few months.
Hematologic/ Lymphatic: Denies any bruising
OBJECTIVE:
Vital signs: Ht: 70, Wt: 265, BP 178/94, HR 92, Resp: 16, SaO2: 95%
Constitutional: Well developed, obese male
HEENT: Oropharynx pink, moist, no lesions or exudate. Tonsils 1+ bilaterally. Teeth in good repair, no cavities noted. Tongue smooth, pink, no lesions, protrudes in midline. Neck supple. No cervical lymphadenopathy or tenderness noted. Thyroid midline, small and firm without palpable masses
Cardiovascular: RRR, No murmurs or rubs noted. No peripheral edema noted
Respiratory: Faint expiratory wheezes noted bilaterally, cleared after coughing.
GI: Abdomen round, soft, with bowel sounds noted in all four quadrants. No organo-megaly noted.
GU: Deferred
Musceloskeletal: Crepatus noted bil knees, no warmth or redness noted.
Integrementary: Skin warm and dry, No rashes noted
Neuro: Follows commands without difficulty
Working with your group, utilize the above case study a, develop a Voice Over PowerPoint presentation for your patient covering the problems identified in the case study and content in Unit 3 of Edelman, Kudzama, & Mandle (2018). Include the following:
2-Health Education
3-Complementary and Alternative Strategies
.
Mrs. Jones is a 32 year old Caucasian female who presents for fo.docx
A 32-year-old woman presents for follow-up for gestational diabetes. She was diagnosed with gestational diabetes during her first pregnancy 3 months ago but has not checked her blood glucose since leaving the hospital due to being busy. She has a strong family history of diabetes and was told to monitor her blood glucose after weaning from breastfeeding. On examination, she is overweight but otherwise healthy. She reports increased fatigue and difficulty sleeping.
Case Study Ankylosing Spondylitis.docx
This case study involves a 65-year-old male presenting with headaches and high blood pressure readings over the past two weeks. On examination, his blood pressure was elevated at 159/92 mmHg. The assessment is essential (primary) hypertension, given his symptoms and blood pressure levels. The plan is to initiate pharmacological treatment with hydrochlorothiazide and provide lifestyle counseling. Follow up with his primary care provider in a week is recommended to monitor his blood pressure and medication management.
Sample Soap NoteSoap Note # Main Diagnosis ( Exp H&P Note .docx
Sample Soap Note:
Soap Note # Main Diagnosis ( Exp: H&P Note #3 DX: Hypertension)
Student Name
Miami Regional University
Date of Encounter:
Preceptor/Clinical Site:
Clinical Instructor: Dr. Rafael Camejo
Soap Note #
Main Diagnosis
( Exp: Soap Note #3 DX: Hypertension)
PATIENT INFORMATION
Name
: Mr. DT
Age
: 68-year-old
Gender at Birth:
Male
Gender Identity
: Male
Source
: Patient
Allergies
: PCN, Iodine
Current Medications:
· Atorvastatin tab 20 mg, 1-tab PO at bedtime
· ASA 81mg po daily
· Multi-Vitamin Centrum Silver
PMH:
Hypercholesterolemia
Immunizations:
Influenza last 2018-year, tetanus, and hepatitis A and B 4 years ago.
Preventive Care
: Coloscopy 5 years ago (Negative)
Surgical History
: Appendectomy 47 years ago.
Family History
: Father- died 81 does not report information
Mother-alive, 88 years old, Diabetes Mellitus, HTN
Daughter-alive, 34 years old, healthy
Social History
: No smoking history or illicit drug use, occasional alcoholic beverage consumption on social celebrations. Retired, widow, he lives alone.
Sexual Orientation
: Straight
Nutrition History
: Diets off and on, Does not each seafood
Subjective Data:
Chief Complaint
: “headaches” that started two weeks ago
Symptom analysis/HPI:
The patient is 65 years old male who complaining of episodes of headaches and on 3 different occasions blood pressure was measured, which was high (159/100, 158/98 and 160/100 respectively). Patient noticed the problem started two weeks ago and sometimes it is accompanied by dizziness. He states that he has been under stress in his workplace for the last month. Patient denies chest pain, palpitation, shortness of breath, nausea or vomiting.
Review of Systems (ROS)
CONSTITUTIONAL
: Denies fever or chills. Denies weakness or weight loss.
NEUROLOGIC
: Headache and dizziness as describe above. Denies changes in LOC. Denies history of tremors or seizures.
HEENT
: HEAD: Denies any head injury, or change in LOC. Eyes: Denies any changes in vision, diplopia or blurred vision. Ear: Denies pain in the ears. Denies loss of hearing or drainage. Nose: Denies nasal drainage, congestion. THROAT: Denies throat or neck pain, hoarseness, difficulty swallowing.
RESPIRATORY
: Patient denies shortness of breath, cough or hemoptysis.
CARDIOVASCULAR
: No chest pain, tachycardia. No orthopnea or paroxysmal nocturnal
dyspnea.
GASTROINTESTINAL
: Denies abdominal pain or discomfort. Denies flatulence, nausea, vomiting or
diarrhea.
GENITOURINARY
: Denies hematuria, dysuria or change in urinary frequency. Denies difficulty starting/stopping stream of urine or incontinence.
MUSCULOSKELETAL
: Denies falls or pain. Denies hearing a clicking or snapping sound.
SKIN
: No change of coloration such as cyanosis or jaundice, no rashes or pruritus.
Objective Data:
VITAL SIGNS:
Temperature: 98.5 °F, Pulse: 87, BP: 159/92 mmhg, RR 20, PO2-98% on room air, Ht- 6’4”, Wt 200 lb, BMI 25. Report pain 2/10.
GENERAL APPREARANCE
.
soap Duodenal Ulcer.docx
This soap note is for a 68-year-old male presenting with headaches and high blood pressure readings over the past two weeks. On examination, his blood pressure was elevated at 159/92 mmHg. The main diagnosis is essential (primary) hypertension. Differential diagnoses include renal artery stenosis, chronic kidney disease, and hyperthyroidism. The plan is to order labs and diagnostic tests, start antihypertensive medications, implement non-pharmacologic treatments like diet and exercise changes, and follow-up in one week to manage his blood pressure.
Soap Note Hypertension Draft.docx
1. This SOAP note is for a 65-year-old male patient who presented with headaches and high blood pressure readings over the past two weeks.
2. On examination, the patient's blood pressure was 159/92 mmHg. No other abnormalities were found.
3. The patient was diagnosed with essential (primary) hypertension. The treatment plan includes lifestyle modifications and starting hydrochlorothiazide 25 mg daily. Follow-up with his primary care provider in one week is recommended to monitor his blood pressure.
Soap Note # Main Diagnosis ( Exp H&P Note #3 DX Hypertension).docx
Soap Note # Main Diagnosis ( Exp: H&P Note #3 DX: Hypertension)
Student Name
Miami Regional University
Date of Encounter:
Preceptor/Clinical Site:
Clinical Instructor: Dr. Rafael Camejo
Soap Note #
Main Diagnosis
( Exp: Soap Note #3 DX: Hypertension)
PATIENT INFORMATION
Name
: Mr. DT
Age
: 68-year-old
Gender at Birth:
Male
Gender Identity
: Male
Source
: Patient
Allergies
: PCN, Iodine
Current Medications:
· Atorvastatin tab 20 mg, 1-tab PO at bedtime
· ASA 81mg po daily
· Multi-Vitamin Centrum Silver
PMH:
Hypercholesterolemia
Immunizations:
Influenza last 2018-year, tetanus, and hepatitis A and B 4 years ago.
Preventive Care
: Coloscopy 5 years ago (Negative)
Surgical History
: Appendectomy 47 years ago.
Family History
: Father- died 81 does not report information
Mother-alive, 88 years old, Diabetes Mellitus, HTN
Daughter-alive, 34 years old, healthy
Social History
: No smoking history or illicit drug use, occasional alcoholic beverage consumption on social celebrations. Retired, widow, he lives alone.
Sexual Orientation
: Straight
Nutrition History
: Diets off and on, Does not each seafood
Subjective Data:
Chief Complaint
: “headaches” that started two weeks ago
Symptom analysis/HPI:
The patient is 65 years old male who complaining of episodes of headaches and on 3 different occasions blood pressure was measured, which was high (159/100, 158/98 and 160/100 respectively). Patient noticed the problem started two weeks ago and sometimes it is accompanied by dizziness. He states that he has been under stress in his workplace for the last month. Patient denies chest pain, palpitation, shortness of breath, nausea or vomiting.
Review of Systems (ROS)
CONSTITUTIONAL
: Denies fever or chills. Denies weakness or weight loss.
NEUROLOGIC
: Headache and dizziness as describe above. Denies changes in LOC. Denies history of tremors or seizures.
HEENT
: HEAD: Denies any head injury, or change in LOC. Eyes: Denies any changes in vision, diplopia or blurred vision. Ear: Denies pain in the ears. Denies loss of hearing or drainage. Nose: Denies nasal drainage, congestion. THROAT: Denies throat or neck pain, hoarseness, difficulty swallowing.
RESPIRATORY
: Patient denies shortness of breath, cough or hemoptysis.
CARDIOVASCULAR
: No chest pain, tachycardia. No orthopnea or paroxysmal nocturnal
dyspnea.
GASTROINTESTINAL
: Denies abdominal pain or discomfort. Denies flatulence, nausea, vomiting or
diarrhea.
GENITOURINARY
: Denies hematuria, dysuria or change in urinary frequency. Denies difficulty starting/stopping stream of urine or incontinence.
MUSCULOSKELETAL
: Denies falls or pain. Denies hearing a clicking or snapping sound.
SKIN
: No change of coloration such as cyanosis or jaundice, no rashes or pruritus.
Objective Data:
VITAL SIGNS:
Temperature: 98.5 °F, Pulse: 87, BP: 159/92 mmhg, RR 20, PO2-98% on room air, Ht- 6’4”, Wt 200 lb, BMI 25. Report pain 2/10.
GENERAL APPREARANCE
: The patient is aler.
Support with 1 journals no older than 5 years. H. Pylori infect.docx
Support with 1 journals no older than 5 years.
H. Pylori infection
Questions: As an NP student, needs to determine the medications for recurrent H. Pylori infection. According to the ACC/AHA Guidelines, what medication should this patient be prescribed? Write her complete prescriptions using the prescription writing format. ACC/AHA Guidelines Chief complaint: “ I have recurrent H. Pylori infection”. HPI: M.C. a 46-year-old hispanic female presents to the GI clinic for complaint of recurrent H. Pylori infection. She was treated about 2 ½ months ago with H. Pylori triple therapy and failed treatment. She has pmhx of dyspepsia, GERD. She also indicates that she has noticed that her symptoms of dyspepsia are worsening for past 2 months. She has associated her symptoms with nausea, upset stomach with all foods. Denies associated symptoms of hematochezia, melena, hemoptysis, abdominal pain, fever, chills, pain or any other symptoms. PMH: H. Pylori infection gastritis Diabetes Mellitus, type 2 Surgeries: None Allergies: NKDA Vaccination History: She receives an annual flu shot. Last flu shot was this year Social history: High school graduate, married and no children. He frequently eats out in restaurants. He drinks one 4-ounce glass of red wine daily. He is a former smoker that stopped 3 years ago. Family history: Both parents are alive. Father has history of DM type 2, Tinea Pedis. mother alive and has history of atopic dermatitis, tinea corporis and tinea pedis. ROS: Constitutional: Negative for fever. Negative for chills. Respiratory: No Shortness of breath. No Orthopnea Cardiovascular: No edema. No palpitations. Gastrointestinal: No vomiting. +Dyspepsia. + Nausea. No constipation. No melena. No abdominal pain. Skin: No lesions. No rash. No itching. Psychiatric: No anxiety. No depression. Physical examination: Vital Signs Height: 5 feet 5 inches Weight: 140 pounds BMI: 31 obesity, BP 110/70 T 98.0 po P 80 R 22, non-labored HEENT: Normocephalic/Atraumatic, PERRL, EOMI; No teeth loss seen. Gums no redness. NECK: Neck supple, no palpable masses, no lymphadenopathy, no thyroid enlargement. LUNGS: Lungs clear bilaterally. Equal breath sounds. Symmetrical respiration. No respiratory distress. HEART: Normal S1 with S2 during expiration. Pulses are 2+ in upper extremities. No edema. ABDOMEN: No abdominal distention. Nontender. Bowel sounds + x 4 quadrants. No organomegaly. Normal contour; No palpable masses. GENITOURINARY: No CVA tenderness bilaterally. GU exam deferred. MUSCULOSKELETAL: Slow gait but steady. No Kyphosis. SKIN: Dry. Intact. PSYCH: Normal affect. Cooperative. Labs day of visit:: Hgb 15.2, Hct 40%, K+ 4.0, Na+137, Serum Creatinine normal 1.0, AST/ALT normal. TSH 3.7 normal, glucose 98 normal A: Primary Diagnosis: Recurrent H. Pylori infection gastritis Secondary Diagnoses: Dyspepsia Differential Diagnosis: Peptic Ulcer Disease Previous medication plan: two month ...
Soap notes will be uploaded to Moodle and put through TURN-It-In (an
Soap notes will be uploaded to Moodle and put through TURN-It-In (anti-Plagiarism program)
Turn it in Score must be less than 50% or will not be accepted for credit, must be your own work and in your own words. You can resubmit, Final submission will be accepted if less than 50%. Copy paste from websites or textbooks will not be accepted or tolerated. Please see College Handbook with reference to Academic Misconduct Statement.
Example:
PATIENT INFORMATION
Name: Mr. W.S.
Age: 65-year-old
Sex: Male
Source: Patient
Allergies: None
Current Medications: Atorvastatin tab 20 mg, 1-tab PO at bedtime
PMH: Hypercholesterolemia
Immunizations: Influenza last 2018-year, tetanus, and hepatitis A and B 4 years ago.
Surgical History: Appendectomy 47 years ago.
Family History: Father- died 81 does not report information
Mother-alive, 88 years old, Diabetes Mellitus, HTN
Daughter-alive, 34 years old, healthy
Social Hx: No smoking history or illicit drug use, occasional alcoholic beverage consumption on social celebrations. Retired, widow, he lives alone.
SUBJECTIVE:
Chief complain
: “headaches” that started two weeks ago
Symptom analysis/HPI:
The patient is 65 years old male who complaining of episodes of headaches and on 3 different occasions blood pressure was measured, which was high (159/100, 158/98 and 160/100 respectively). Patient noticed the problem started two weeks ago and sometimes it is accompanied by dizziness.He states that he has been under stress in his workplace for the last month.
Patient denies chest pain, palpitation, shortness of breath, nausea or vomiting.
ROS:
CONSTITUTIONAL
: Denies fever or chills. Denies weakness or weight loss.
NEUROLOGIC
: Headache and dizzeness as describe above. Denies changes in LOC. Denies history of tremors or seizures.
HEENT
: HEAD: Denies any head injury, or change in LOC. Eyes: Denies any changes in vision, diplopia or blurred vision. Ear: Denies pain in the ears. Denies loss of hearing or drainage. Nose: Denies nasal drainage, congestion. THROAT: Denies throat or neck pain, hoarseness, difficulty swallowing.
Respiratory
:Patient denies shortness of breath, cough or hemoptysis.
Cardiovascular
: No chest pain, tachycardia. No orthopnea or paroxysmal nocturnal
dyspnea.
Gastrointestinal
:Denies abdominal pain or discomfort.Denies flatulence, nausea, vomiting or
diarrhea.
Genitourinary
: Denies hematuria, dysuria or change in urinary frequency. Denies difficulty starting/stopping stream of urine or incontinence.
MUSCULOSKELETAL
: Denies falls or pain. Denies hearing a clicking or snapping sound.
Skin
: No change of coloration such as cyanosis or jaundice, no rashes or pruritus.
Objective Data
CONSTITUTIONAL
: Vital signs: Temperature: 98.5 °F, Pulse: 87, BP: 159/92 mmhg, RR 20, PO2-98% on room air, Ht- 6’4”, Wt 200 lb, BMI 25. Report pain 0/10.
General appearance: The patient is alert and oriented x 3. No acute distress noted.
NEUROLOGIC:
Alert, CNII-XII grossly intac ...
Pulmonary Case PresentationsPlease select one case presentation be.docx
Pulmonary Case Presentations
Please select one case presentation below and provide answers to the following;
Three differential diagnoses
Definitive diagnosis
Management plan (include appropriate treatment/diagnostic tests)
Indications for referral and/or consultations (if needed)
Health education/lifespan considerations
Schedule a F/U appointment
Case I:
50 Y/O CM present with C/O dry cough x 4-5 months with 20 year H/O tobacco use of 1PPD for 20 years. Cough has become progressively worse over the past 2-3 weeks with yellow sputum production. Took OTC cough syrup without relief of symptoms. Afebrile at home. No CP or fatigue except with excessive coughing. No HAs or head injuries. No eye pain or drainage. No ear pain or difficulty hearing. Ocass. nasal drainage of clear mucus. No sore throat or difficulty swallowing. No neck pain or stiffness. Some SOB with excessive coughing. Excessive coughing interferes with ability to perform ADLs at times. No other household members with similar symptoms.
Temp--97.2
Pulse--94
B/P 140/90
RR- 24
Pulse Ox check-- 86% on Room Air
General: Alert, apprehensive but cooperative
SKIN: W/D with rapid recoil
HEENT: Normocephalic. PERRL, sclera clear, Bil. TMs pearly gray. Boggy, pale nasal mucosa. Oropharynx without erythema or exudate
NECK: Supple without LAD (lymphadenopathy)
HEART: Tachycardia without murmur, gallops or clicks
RESP: Distant lung sounds; positive rales at base with expiratory wheezes
Case II: (mom is present and is historian)
3 Y/O Asian male present with 3 day H/O dry cough that’s worse when playing outside near Spring flowers. Took OTC cough suppressant with cough resolved but reoccurred. Afebrile at home. Positive sneezing and itchy eyes at times. Consumes fluid and solid foods without difficulty. Mom reports tiring easily when outside playing with other children in neighborhood. No SOB noted per mom. Remain active and playful. No change in urinary habits with last BM this a.m, of soft brown consistency.
Temp--98.4
Pulse--104
B/P 80/68
RR- 26
Pulse Ox check-- 95%
General: Alert, cooperative without distress.
SKIN: W/D with rapid recoil
HEENT: Normocephalic. PERRL, sclera clear, Bil.TMs pearly gray. Boggy, pale nasal mucosa. O/P without erythema, masses, or lesions. Pink, moist mucous membranes.
NECK: Supple without LAD
HEART: Regular rate and rhythm (RRR) without murmur
RESP: Expiratory wheezing without retractions or nasal flaring
ABD: Soft, round, NT with positive BS
Case III:
J. V., a 24-year-old man, is admitted to the emergency department after a motorcycle accident. He is having trouble in breathing and is very upset. The rescue personnel tell you that his breath sounds are absent on the right side, his chest expands unequally, and that there is tracheal shift toward the left. There is a large contusion on his right rib cage.
Temp--97.2
Pulse--110
B/P 140/92
RR- 28
Pulse Ox check-- 88%
General: Alert & apprehensive
SKIN: Cool & diaphoretic; bluish discoloration to right anterior thorax.
Week 8GI Case Study H. Pylori infectionQuestions As an.docx
Week 8
GI Case Study: H. Pylori infection
Questions: As an NP student, needs to determine the medications for recurrent H. Pylori infection.
According to the ACC/AHA Guidelines, what medication should this patient be prescribed? Write her complete prescriptions using the prescription writing format.
ACC/AHA Guidelines
Chief complaint:
“ I have recurrent H. Pylori infection”.
HPI:
M.C. a 46-year-old hispanic female presents to the GI clinic for complaint of recurrent H. Pylori infection. She was treated about 2 ½ months ago with H. Pylori triple therapy and failed treatment. She has pmhx of dyspepsia, GERD.
She also indicates that she has noticed that her symptoms of dyspepsia are worsening for past 2 months. She has associated her symptoms with nausea, upset stomach with all foods.
Denies associated symptoms of hematochezia, melena, hemoptysis, abdominal pain, fever, chills, pain or any other symptoms.
PMH:
H. Pylori infection gastritis
Diabetes Mellitus, type 2
Surgeries: None
Allergies
:
NKDA
Vaccination History:
She receives an annual flu shot. Last flu shot was this year
Social history:
High school graduate, married and no children. He frequently eats out in restaurants. He drinks one 4-ounce glass of red wine daily. He is a former smoker that stopped 3 years ago.
Family history:
Both parents are alive. Father has history of DM type 2, Tinea Pedis.
mother alive and has history of atopic dermatitis, tinea corporis and tinea pedis.
ROS:
Constitutional: Negative for fever. Negative for chills.
Respiratory: No Shortness of breath. No Orthopnea
Cardiovascular: No edema. No palpitations.
Gastrointestinal: No vomiting. +Dyspepsia. + Nausea. No constipation. No melena. No abdominal pain.
Skin: No lesions. No rash. No itching.
Psychiatric: No anxiety. No depression.
Physical examination:
Vital Signs
Height: 5 feet 5 inches Weight: 140 pounds BMI: 31 obesity, BP 110/70 T 98.0 po P 80 R 22, non-labored
HEENT
: Normocephalic/Atraumatic, PERRL, EOMI; No teeth loss seen. Gums no redness.
NECK
: Neck supple, no palpable masses, no lymphadenopathy, no thyroid enlargement.
LUNGS
: Lungs clear bilaterally. Equal breath sounds. Symmetrical respiration. No respiratory distress.
HEART
: Normal S1 with S2 during expiration. Pulses are 2+ in upper extremities. No edema.
ABDOMEN
: No abdominal distention. Nontender. Bowel sounds + x 4 quadrants. No organomegaly. Normal contour; No palpable masses.
GENITOURINARY
: No CVA tenderness bilaterally. GU exam deferred.
MUSCULOSKELETAL
: Slow gait but steady. No Kyphosis.
SKIN:
Dry. Intact.
PSYCH
: Normal affect. Cooperative.
Labs day of visit
:: Hgb 15.2, Hct 40%, K+ 4.0, Na+137, Serum Creatinine normal 1.0, AST/ALT normal. TSH 3.7 normal, glucose 98 normal
A:
Primary Diagnosis: Recurrent H. Pylori infection gastritis
Secondary Diagnoses:
Dyspepsia
Differential Diagnosis:
Peptic Ulcer Disease
Previous medication plan:
two months ago and failed.
Clarithromycin 500 m ...
(Student Name) UniversityDate of EncounterPreceptorClini
(Student Name)
University
Date of Encounter:
Preceptor/Clinical Site:
Clinical Instructor:
Soap Note # Main Diagnosis ( Exp: Soap Note #3 DX: Hypertension)
PATIENT INFORMATION
Name: Mr. DT
Age: 68-year-old
Gender at Birth: Male
Gender Identity: Male
Source: Patient
Allergies: PCN, Iodine
Current Medications:
· Atorvastatin tab 20 mg, 1-tab PO at bedtime
· ASA 81mg po daily
· Multi-Vitamin Centrum Silver
PMH: Hypercholesterolemia
Immunizations: Influenza last 2018-year, tetanus, and hepatitis A and B 4 years ago.
Preventive Care: Coloscopy 5 years ago (Negative)
Surgical History: Appendectomy 47 years ago.
Family History: Father- died 81 does not report information
Mother-alive, 88 years old, Diabetes Mellitus, HTN
Daughter-alive, 34 years old, healthy
Social History: No smoking history or illicit drug use, occasional alcoholic beverage consumption on social celebrations. Retired, widow, he lives alone.
Sexual Orientation: Straight
Nutrition History: Diets off and on, Does not each seafood
Subjective Data:
Chief Complaint: “headaches” that started two weeks ago
Symptom analysis/HPI:
The patient is 65 years old male who complaining of episodes of headaches and on 3 different occasions blood pressure was measured, which was high (159/100, 158/98 and 160/100 respectively). Patient noticed the problem started two weeks ago and sometimes it is accompanied by dizziness. He states that he has been under stress in his workplace for the last month. Patient denies chest pain, palpitation, shortness of breath, nausea or vomiting.
Review of Systems (ROS)
CONSTITUTIONAL: Denies fever or chills. Denies weakness or weight loss. NEUROLOGIC: Headache and dizziness as describe above. Denies changes in LOC. Denies history of tremors or seizures.
HEENT: HEAD: Denies any head injury, or change in LOC. Eyes: Denies any changes in vision, diplopia or blurred vision. Ear: Denies pain in the ears. Denies loss of hearing or drainage. Nose: Denies nasal drainage, congestion. THROAT: Denies throat or neck pain, hoarseness, difficulty swallowing.
RESPIRATORY: Patient denies shortness of breath, cough or hemoptysis.
CARDIOVASCULAR: No chest pain, tachycardia. No orthopnea or paroxysmal nocturnal
dyspnea.
GASTROINTESTINAL: Denies abdominal pain or discomfort. Denies flatulence, nausea, vomiting or
diarrhea.
GENITOURINARY: Denies hematuria, dysuria or change in urinary frequency. Denies difficulty starting/stopping stream of urine or incontinence.
MUSCULOSKELETAL: Denies falls or pain. Denies hearing a clicking or snapping sound.
SKIN: No change of coloration such as cyanosis or jaundice, no rashes or pruritus.
Objective Data:
VITAL SIGNS: Temperature: 98.5 °F, Pulse: 87, BP: 159/92 mmhg, RR 20, PO2-98% on room air, Ht- 6’4”, Wt 200 lb, BMI 25. Report pain 2/10.
GENERAL APPREARANCE: The patient is alert and oriented x 3. No acute distress noted. NEUROLOGIC: Alert, CNII-XII grossly intact, oriented to person, ...
(Student Name) UniversityDate of EncounterPreceptorClini
1. The patient is a 68-year-old male who presented with headaches and high blood pressure readings over the past two weeks. On examination, his blood pressure was elevated at 159/92 mmHg.
2. The main diagnosis is essential (primary) hypertension given the symptoms and elevated blood pressure readings with no identifiable cause found. Differential diagnoses considered include renal artery stenosis, chronic kidney disease, and hyperthyroidism.
3. Labs, diagnostic tests, pharmacologic treatment with hydrochlorothiazide and lisinopril, and non-pharmacologic recommendations including lifestyle changes and follow up in 1 week are included in the treatment plan.
Knowledge of anatomy.docx
A 42-year-old African American male presents with lower back pain radiating to his left leg for the past month. Based on the patient's medical history and description of symptoms, the nerve roots involved could be L4, L5, or S1, which can be tested via straight leg raise test. Differential diagnoses include herniated disc, spinal stenosis, or sciatica. A physical exam and special maneuvers like straight leg raise test are needed to determine the cause and guide treatment.
case presentation respiratoy.pptx
Mrs. I.B, a 48 year old female, presented with complaints of recurrent cough for 1 year and breathlessness for 1 month, associated with hemoptysis, night sweats, and weight loss. She has a history of 3 previous treatments for pulmonary tuberculosis. On examination, she was in respiratory distress with clubbing and reduced breath sounds on the right lung. Investigations showed anemia, elevated ESR, and chest X-ray findings of post-TB changes. She was diagnosed with post-TB bronchiectasis exacerbated by chronic pulmonary aspergillosis.
Soap notes will be uploaded to Moodle and put through.docx
This soap note documents a visit for a 65-year-old male patient complaining of headaches for the past two weeks. On examination, the patient's blood pressure was elevated on multiple readings. The assessment is essential (primary) hypertension. The plan includes starting hydrochlorothiazide 25 mg daily, as well as lifestyle modifications and follow up with his primary care provider in one week to evaluate blood pressure control. No referrals are needed at this time.
Support with 1 journals no older than 5 years.Week 8GI Case .docx
Support with 1 journals no older than 5 years.
Week 8
GI Case Study: H. Pylori infection
Questions: As an NP student, needs to determine the medications for recurrent H. Pylori infection.
According to the ACC/AHA Guidelines, what medication should this patient be prescribed? Write her complete prescriptions using the prescription writing format.
ACC/AHA Guidelines
Chief complaint:
“ I have recurrent H. Pylori infection”.
HPI:
M.C. a 46-year-old hispanic female presents to the GI clinic for complaint of recurrent H. Pylori infection. She was treated about 2 ½ months ago with H. Pylori triple therapy and failed treatment. She has pmhx of dyspepsia, GERD.
She also indicates that she has noticed that her symptoms of dyspepsia are worsening for past 2 months. She has associated her symptoms with nausea, upset stomach with all foods.
Denies associated symptoms of hematochezia, melena, hemoptysis, abdominal pain, fever, chills, pain or any other symptoms.
PMH:
H. Pylori infection gastritis
Diabetes Mellitus, type 2
Surgeries: None
Allergies
:
NKDA
Vaccination History:
She receives an annual flu shot. Last flu shot was this year
Social history:
High school graduate, married and no children. He frequently eats out in restaurants. He drinks one 4-ounce glass of red wine daily. He is a former smoker that stopped 3 years ago.
Family history:
Both parents are alive. Father has history of DM type 2, Tinea Pedis.
mother alive and has history of atopic dermatitis, tinea corporis and tinea pedis.
ROS:
Constitutional: Negative for fever. Negative for chills.
Respiratory: No Shortness of breath. No Orthopnea
Cardiovascular: No edema. No palpitations.
Gastrointestinal: No vomiting. +Dyspepsia. + Nausea. No constipation. No melena. No abdominal pain.
Skin: No lesions. No rash. No itching.
Psychiatric: No anxiety. No depression.
Physical examination:
Vital Signs
Height: 5 feet 5 inches Weight: 140 pounds BMI: 31 obesity, BP 110/70 T 98.0 po P 80 R 22, non-labored
HEENT
: Normocephalic/Atraumatic, PERRL, EOMI; No teeth loss seen. Gums no redness.
NECK
: Neck supple, no palpable masses, no lymphadenopathy, no thyroid enlargement.
LUNGS
: Lungs clear bilaterally. Equal breath sounds. Symmetrical respiration. No respiratory distress.
HEART
: Normal S1 with S2 during expiration. Pulses are 2+ in upper extremities. No edema.
ABDOMEN
: No abdominal distention. Nontender. Bowel sounds + x 4 quadrants. No organomegaly. Normal contour; No palpable masses.
GENITOURINARY
: No CVA tenderness bilaterally. GU exam deferred.
MUSCULOSKELETAL
: Slow gait but steady. No Kyphosis.
SKIN:
Dry. Intact.
PSYCH
: Normal affect. Cooperative.
Labs day of visit
:: Hgb 15.2, Hct 40%, K+ 4.0, Na+137, Serum Creatinine normal 1.0, AST/ALT normal. TSH 3.7 normal, glucose 98 normal
A:
Primary Diagnosis: Recurrent H. Pylori infection gastritis
Secondary Diagnoses:
Dyspepsia
Differential Diagnosis:
Peptic Ulcer Disease
Previous medic ...
SOAP NOTEName J.D.Date 03262020Time 200 pmAge 25 .docx
SOAP NOTE
Name: J.D.
Date: 03/26/2020
Time: 2:00 pm
Age: 25 y/o
Sex: F
SUBJECTIVE
CC:
” I have a lot of pain on my left side, in my lower belly”
HPI: J.D. is a 25-year-old white female that came to the office today complaining of pain in her lower abdomen. The patient has always had painful cramps with her periods but this time it is much worse being described as a 6 out of 10 and lasting up to 5 hours. The pain started 2 days ago. The pain is described as more painful cramps. It is debilitating and prevents the patient from performing most daily activities. It is localized in the lower abdominal area, and sometimes radiates down her legs, and to her lower back. The patient uses hot compresses to relieve the pain as Tylenol does not work. The patient also states that she has been feeling nauseous ever since the pain started. She also urinates more frequently and pain on urination. Denies fever, vomiting, or chills.
Medications:
2 Tylenol as needed for her pain
PMH (include-immunization status including Gardisil, GTPLA).
Current or past illnesses: No current or past illnesses
Immunizations: All vaccines updated including flu vaccine and Gardasil.
Allergies: NKDA
Medication Intolerances: None.
Chronic Illnesses/Major traumas: None.
Hospitalizations/Surgeries (include delivery of pregnancies here)
No hospitalizations.
G0P0
Family History
Mother: 49 years old, no significant health problems
Maternal Side: No significant health problems
Father: 50 years old, hypertensive
Paternal Side: no significant health problems
Social History
Patient works full-time as a research assistant at a local university. A full-time student seeking a master’s degree in biochemistry at a local university. Married. Sexually active only with husband. Always uses male condoms as contraceptive device. Does not use recreational drugs, tobacco, or electronic cigarettes. Devout follower of Christianity. Denomination: catholic.
ROS
General Patient denies fever or chills, no weight changes.
Cardiovascular Denies chest pain, or discomfort. Denies palpitations, dyspnea, or orthopnea.
Skin: Denies presences of moles, rash, or itching.
Respiratory: Denies dyspnea, cough, hemoptysis, or pleuritic pains.
Eyes Denies problems or changes in her vision; denies double or blurred vision.
Gastrointestinal Positive for nausea.Denies hemorrhoids, constipation, or diarrhea. No variation in bowel habits. Denies vomiting.
Ears Denies difficulty or changes in his hearing. Denies tinnitus, or discharges.
Genitourinary/Gynecological Menarche 11 years old. Regular menstrual periods starting around the 3rd week of every month. LMP: 03.
Soap notes will be uploaded to Moodle and put through TURN-It-In (anti.docx
Soap notes will be uploaded to Moodle and put through TURN-It-In (anti-Plagiarism program)
Turn it in Score must be less than 50% or will not be accepted for credit, must be your own work and in your own words. You can resubmit, Final submission will be accepted if less than 50%. Copy paste from
websites
or textbooks will not be accepted or tolerated. Please see College Handbook with reference to Academic Misconduct Statement.
Example:
PATIENT INFORMATION
Name: Mr. W.S.
Age: 65-year-old
Sex: Male
Source: Patient
Allergies: None
Current Medications: Atorvastatin tab 20 mg, 1-tab PO at bedtime
PMH: Hypercholesterolemia
Immunizations: Influenza last 2018-year, tetanus, and hepatitis A and B 4 years ago.
Surgical History: Appendectomy 47 years ago.
Family History: Father- died 81 does not report information
Mother-alive, 88 years old, Diabetes Mellitus, HTN
Daughter-alive, 34 years old, healthy
Social Hx: No smoking history or illicit drug use, occasional alcoholic beverage consumption on social celebrations. Retired, widow, he lives alone.
SUBJECTIVE:
Chief complain
: “headaches†that started two weeks ago
Symptom analysis/HPI:
The patient is 65 years old male who complaining of episodes of headaches and on 3 different occasions blood pressure was measured, which was high (159/100, 158/98 and 160/100 respectively). Patient noticed the problem started two weeks ago and sometimes it is accompanied by dizziness. He states that he has been under stress in his workplace for the last month.
Patient denies chest pain, palpitation, shortness of breath, nausea or vomiting.
ROS:
CONSTITUTIONAL
: Denies fever or chills. Denies weakness or weight loss.
NEUROLOGIC
: Headache and dizziness as describe above. Denies changes in LOC. Denies history of tremors or seizures.
HEENT
: HEAD: Denies any head injury, or change in LOC. Eyes: Denies any changes in vision, diplopia or blurred vision. Ear: Denies pain in the ears. Denies loss of hearing or drainage. Nose: Denies nasal drainage, congestion. THROAT: Denies throat or neck pain, hoarseness, difficulty swallowing.
Respiratory
: Patient denies shortness of breath, cough or hemoptysis.
Cardiovascular
: No chest pain, tachycardia. No orthopnea or paroxysmal nocturnal
dyspnea.
Gastrointestinal
: Denies abdominal pain or discomfort. Denies flatulence, nausea, vomiting or
diarrhea.
Genitourinary
: Denies hematuria, dysuria or change in urinary frequency. Denies difficulty starting/stopping stream of urine or incontinence.
MUSCULOSKELETAL
: Denies falls or pain. Denies hearing a clicking or snapping sound.
Skin
: No change of coloration such as cyanosis or jaundice, no rashes or pruritus.
Objective Data
CONSTITUTIONAL
: Vital signs: Temperature: 98.5 °F, Pulse: 87, BP: 159/92 mmhg, RR 20, PO2-98% on room air, Ht- 6’4â€, Wt 200 lb, BMI 25. Report pain 0/10.
General appearance: The patient is alert and oriented x 3. No acute dist.
62181184 quinx-case-study
Mrs. A, a 76-year-old woman with a history of hypertension and stroke, presented with body weakness. Her physical exam found weakness on her right side and enlarged heart on chest x-ray. Lab results showed abnormal cholesterol and electrolyte levels. She was diagnosed with uncontrolled hypertension and given medications to control her blood pressure along with dietary and lifestyle counseling upon discharge.
Case StudyChief complaint I’m here for a medication refill .docx
Case Study:
Chief complaint:
“I’m here for a medication refill because I ran out of my medicines”.
HPI:
Mrs. Allen is a 68-year-old African American who presents to the clinic for prescription refills. The patient indicates that she has noticed shortness of breath which started about 3 months ago. The SOB gets worse with exertion, especially when she is walking fast, and it is resolved when she is resting. She reports that she is also bothered by shortness of breath that wakes her up intermittently during her sleep. Her symptoms of shortness of breath resolve after sitting upright on 3 pillows. She also has lower leg edema pitting 1+ which started 2 weeks ago. She indicates that she often feels light headed at times with intermittent syncope episodes while going up a flight of stairs, but it resolves after sitting down to rest. She has not tried any over the counter medications at home.
She started taking her medications, but failed to refill the prescriptions because she cannot afford the medications as she only works part-time and lives alone. In addition, she reports that she does not think taking all these medications would help her condition anyway.
PMH:
Primary Hypertension, Previous history of MI 1 year ago
Surgeries:
1 year ago-Left Anterior Descending (LAD) cardiac stent placement
Allergies
:
Penicillin
Vaccination History:
Up-to-date
Social history:
High school graduate married and no children. Drinks one 4-ounce glass of red wine daily. She is a former smoker and stopped 5 years ago.
Family history:
Both parents are alive. Father has history of MI and valvular heart disease; mother alive and cardiac history is unknown. He has one brother who is alive and has history of MI 5 years ago at age 52.
ROS:
Constitutional: Lightheaded and faint with exertion. Respiratory: Shortness of breath with exertion. + Orthopnea. Cardiovascular: + 2 pitting leg edema for 3 weeks.
Psychiatric: Non-contributory.
Physical examination:
Vital Signs:
Height: 5 feet 1 inches Weight: 175 pounds BMI: 32, Obese, BP 160/92, T 98.0, P 111, R 22 and non-labored
HEENT
: Normocephalic/Atraumatic, Bilateral cataracts; PERRLA, EOMI; Teeth intact. Negative for gum disease.
NECK
: Neck supple, no palpable masses, no lymphadenopathy, no thyroid enlargement.
LUNGS
: + Mild Crackles on inspiratory phase not clearing with cough. Equal breath sounds. Symmetrical respiration. No respiratory distress.
HEART
: Normal S1 with S2 during expiration. An S4 is noted at the apex; + systolic murmur noted at the right upper sternal border without radiation to the carotids. Pulses are 2+ in upper extremities and 2+ in pedal pulses bilaterally. 2+ pitting edema to her knees noted bilaterally.
ABDOMEN
: No abdominal distention. Nontender. Bowel sounds + x 4 quadrants. No organomegaly. Normal contour; No palpable masses.
GENITOURINARY
: No CVA tenderness bilaterally. GU exam deferred.
MUSCULOSKELETAL
: + Heberden's nodes at the DIP joints, hands. + Crepi.
Give an example from your own experience or research an article or.docx
Give an example from your own experience or research an article or the media in which a business executive did something of significance that is morally right. Use APA format to cite your material from your sources.
Is there a relationship between obesity and socio-economic status? Should obese people be considered a protected class under Title VII of the Civil Rights Act?
1:
2:
3.
4.
5.
Comprehensive SOAP Exemplar
Purpose: To demonstrate what each section of the SOAP Note should include. Remember that nurse practitioners treat patients in a holistic manner, and your SOAP Note should reflect that premise.
Patient Initials: _______
Age: _______
Gender: _______
SUBJECTIVE DATA:
Chief Complaint (CC): Coughing up phlegm and fever
History of Present Illness (HPI): Sara Jones is a 65-year-old Caucasian female who presents today with a productive cough x 3 weeks and fever for the last 3 days. She reported that the “cold feels like it is descending into her chest.” The cough is nagging and productive. She brought in a few paper towels with expectorated phlegm – yellow/brown in color. She has associated symptoms of dyspnea of exertion and fever. Her Tmax was reported to be 102.4 last night. She has been taking Ibuprofen 400mg about every 6 hours and the fever breaks, but it returns after the medication wears off. She rated the severity of her symptom discomfort at 4/10.
Medications:
1.) Lisinopril 10mg daily
2.) Combivent 2 puffs every 6 hours as needed
3.) Serovent daily
4.) Salmeterol daily
5.) Over-the-counter Ibuprofen 200mg -2 PO as needed
6.) Over-the-counter Benefiber
7.) Flonase 1 spray each night as needed for allergic rhinitis symptoms
Allergies:
Sulfa drugs - rash
Past Medical History (PMH):
1.) Emphysema with recent exacerbation 1 month ago – deferred admission – RX’d with outpatient antibiotics and hand held nebulizer treatments.
2.) Hypertension – well controlled
3.) Gastroesophageal reflux (GERD) – quiet, on no medication
4.) Osteopenia
5.) Allergic rhinitis
Past Surgical History (PSH):
1.) Cholecystectomy 1994
2.) Total abdominal hysterectomy (TAH) 1998
Sexual/Reproductive History:
Heterosexual
G1P1A0
Non-menstruating – TAH 1998
Personal/Social History:
She has smoked 2 packs of cigarettes daily x 30 years; denied ETOH or illicit drug use.
Immunization History:
Her immunizations are up to date. She received the influenza vaccine last November and the Pneumococcal vaccine at the same time.
Significant Family History:
Two brothers – one with diabetes, dx at age 65, and the other with prostate CA, dx at age 62. She has one daughter in her 30s, healthy, living in nearby neighborhood.
Lifestyle:
She is retired, has been widowed x 8 years, and lives in the city in a moderate crime area with good public transportation. She is a college graduate, owns her home, and receives a pension of $50,000 annually – financially stable.
She has a primary care nurse practitioner provider and goes for annual and r ...
Hypertension
This document presents a case study of a 47-year-old female patient named Mrs. Dhakshayani who is being treated for hypertension. She has been taking medication for hypertension for 1 year. On examination, her blood pressure was found to be 178/90 mmHg, indicating stage 2 hypertension. She has a family history of hypertension in her husband. Her diet lacks vegetables and fruits. The provisional diagnosis is stage 2 hypertension. The goals are to reduce her weight by 5-7 kg through a low sodium, low fat diet and increased physical activity, and to bring her blood pressure under control through regular medical checkups and medication compliance.
Discussion 1Choose any four ‘causes’ of change within a projec.docx
Discussion 1
Choose any four ‘causes’ of change within a project in table 9.1 in the text. Provide a project example and scenario, and describe the impact of each change. Was there a level of change control in the project examples that tracked ownership, documentation and approval of these changes?
Discussion 2
The identification of all changes to a project is only the first step for ensuring a control system is in place. Describe the detailed steps you would implement for your project to ensure an entire change control process is in place. Consider the following topics in your answer: documentation, analysis, approval and implementation. Why is the baseline configuration important to this topic?
.
DISCUSSION 1Community and Health Information Networks Please .docx
A key trend supporting CHINs and RHINOs is increased data sharing across organizations to improve care coordination. Transitioning from CHINs to RHINOs has more benefits than challenges as it allows for broader sharing of health information across larger regions. Integrating CPOE and CDSS into EHRs has the advantage of catching errors and providing treatment recommendations to improve patient safety and outcomes. Electronic database systems are more efficient than paper records as they reduce errors, save space, and allow easy access to records. The main advantages of EMRs are reduced errors, easy sharing of information, and improved treatment while the disadvantages include costs of implementation and concerns about privacy and security.
More Related Content
Similar to Hypertension Case StudyC.D is a 55-year-old African American male
Sample Soap NoteSoap Note # Main Diagnosis ( Exp H&P Note .docx
Sample Soap Note:
Soap Note # Main Diagnosis ( Exp: H&P Note #3 DX: Hypertension)
Student Name
Miami Regional University
Date of Encounter:
Preceptor/Clinical Site:
Clinical Instructor: Dr. Rafael Camejo
Soap Note #
Main Diagnosis
( Exp: Soap Note #3 DX: Hypertension)
PATIENT INFORMATION
Name
: Mr. DT
Age
: 68-year-old
Gender at Birth:
Male
Gender Identity
: Male
Source
: Patient
Allergies
: PCN, Iodine
Current Medications:
· Atorvastatin tab 20 mg, 1-tab PO at bedtime
· ASA 81mg po daily
· Multi-Vitamin Centrum Silver
PMH:
Hypercholesterolemia
Immunizations:
Influenza last 2018-year, tetanus, and hepatitis A and B 4 years ago.
Preventive Care
: Coloscopy 5 years ago (Negative)
Surgical History
: Appendectomy 47 years ago.
Family History
: Father- died 81 does not report information
Mother-alive, 88 years old, Diabetes Mellitus, HTN
Daughter-alive, 34 years old, healthy
Social History
: No smoking history or illicit drug use, occasional alcoholic beverage consumption on social celebrations. Retired, widow, he lives alone.
Sexual Orientation
: Straight
Nutrition History
: Diets off and on, Does not each seafood
Subjective Data:
Chief Complaint
: “headaches” that started two weeks ago
Symptom analysis/HPI:
The patient is 65 years old male who complaining of episodes of headaches and on 3 different occasions blood pressure was measured, which was high (159/100, 158/98 and 160/100 respectively). Patient noticed the problem started two weeks ago and sometimes it is accompanied by dizziness. He states that he has been under stress in his workplace for the last month. Patient denies chest pain, palpitation, shortness of breath, nausea or vomiting.
Review of Systems (ROS)
CONSTITUTIONAL
: Denies fever or chills. Denies weakness or weight loss.
NEUROLOGIC
: Headache and dizziness as describe above. Denies changes in LOC. Denies history of tremors or seizures.
HEENT
: HEAD: Denies any head injury, or change in LOC. Eyes: Denies any changes in vision, diplopia or blurred vision. Ear: Denies pain in the ears. Denies loss of hearing or drainage. Nose: Denies nasal drainage, congestion. THROAT: Denies throat or neck pain, hoarseness, difficulty swallowing.
RESPIRATORY
: Patient denies shortness of breath, cough or hemoptysis.
CARDIOVASCULAR
: No chest pain, tachycardia. No orthopnea or paroxysmal nocturnal
dyspnea.
GASTROINTESTINAL
: Denies abdominal pain or discomfort. Denies flatulence, nausea, vomiting or
diarrhea.
GENITOURINARY
: Denies hematuria, dysuria or change in urinary frequency. Denies difficulty starting/stopping stream of urine or incontinence.
MUSCULOSKELETAL
: Denies falls or pain. Denies hearing a clicking or snapping sound.
SKIN
: No change of coloration such as cyanosis or jaundice, no rashes or pruritus.
Objective Data:
VITAL SIGNS:
Temperature: 98.5 °F, Pulse: 87, BP: 159/92 mmhg, RR 20, PO2-98% on room air, Ht- 6’4”, Wt 200 lb, BMI 25. Report pain 2/10.
GENERAL APPREARANCE
.
soap Duodenal Ulcer.docx
This soap note is for a 68-year-old male presenting with headaches and high blood pressure readings over the past two weeks. On examination, his blood pressure was elevated at 159/92 mmHg. The main diagnosis is essential (primary) hypertension. Differential diagnoses include renal artery stenosis, chronic kidney disease, and hyperthyroidism. The plan is to order labs and diagnostic tests, start antihypertensive medications, implement non-pharmacologic treatments like diet and exercise changes, and follow-up in one week to manage his blood pressure.
Soap Note Hypertension Draft.docx
1. This SOAP note is for a 65-year-old male patient who presented with headaches and high blood pressure readings over the past two weeks.
2. On examination, the patient's blood pressure was 159/92 mmHg. No other abnormalities were found.
3. The patient was diagnosed with essential (primary) hypertension. The treatment plan includes lifestyle modifications and starting hydrochlorothiazide 25 mg daily. Follow-up with his primary care provider in one week is recommended to monitor his blood pressure.
Soap Note # Main Diagnosis ( Exp H&P Note #3 DX Hypertension).docx
Soap Note # Main Diagnosis ( Exp: H&P Note #3 DX: Hypertension)
Student Name
Miami Regional University
Date of Encounter:
Preceptor/Clinical Site:
Clinical Instructor: Dr. Rafael Camejo
Soap Note #
Main Diagnosis
( Exp: Soap Note #3 DX: Hypertension)
PATIENT INFORMATION
Name
: Mr. DT
Age
: 68-year-old
Gender at Birth:
Male
Gender Identity
: Male
Source
: Patient
Allergies
: PCN, Iodine
Current Medications:
· Atorvastatin tab 20 mg, 1-tab PO at bedtime
· ASA 81mg po daily
· Multi-Vitamin Centrum Silver
PMH:
Hypercholesterolemia
Immunizations:
Influenza last 2018-year, tetanus, and hepatitis A and B 4 years ago.
Preventive Care
: Coloscopy 5 years ago (Negative)
Surgical History
: Appendectomy 47 years ago.
Family History
: Father- died 81 does not report information
Mother-alive, 88 years old, Diabetes Mellitus, HTN
Daughter-alive, 34 years old, healthy
Social History
: No smoking history or illicit drug use, occasional alcoholic beverage consumption on social celebrations. Retired, widow, he lives alone.
Sexual Orientation
: Straight
Nutrition History
: Diets off and on, Does not each seafood
Subjective Data:
Chief Complaint
: “headaches” that started two weeks ago
Symptom analysis/HPI:
The patient is 65 years old male who complaining of episodes of headaches and on 3 different occasions blood pressure was measured, which was high (159/100, 158/98 and 160/100 respectively). Patient noticed the problem started two weeks ago and sometimes it is accompanied by dizziness. He states that he has been under stress in his workplace for the last month. Patient denies chest pain, palpitation, shortness of breath, nausea or vomiting.
Review of Systems (ROS)
CONSTITUTIONAL
: Denies fever or chills. Denies weakness or weight loss.
NEUROLOGIC
: Headache and dizziness as describe above. Denies changes in LOC. Denies history of tremors or seizures.
HEENT
: HEAD: Denies any head injury, or change in LOC. Eyes: Denies any changes in vision, diplopia or blurred vision. Ear: Denies pain in the ears. Denies loss of hearing or drainage. Nose: Denies nasal drainage, congestion. THROAT: Denies throat or neck pain, hoarseness, difficulty swallowing.
RESPIRATORY
: Patient denies shortness of breath, cough or hemoptysis.
CARDIOVASCULAR
: No chest pain, tachycardia. No orthopnea or paroxysmal nocturnal
dyspnea.
GASTROINTESTINAL
: Denies abdominal pain or discomfort. Denies flatulence, nausea, vomiting or
diarrhea.
GENITOURINARY
: Denies hematuria, dysuria or change in urinary frequency. Denies difficulty starting/stopping stream of urine or incontinence.
MUSCULOSKELETAL
: Denies falls or pain. Denies hearing a clicking or snapping sound.
SKIN
: No change of coloration such as cyanosis or jaundice, no rashes or pruritus.
Objective Data:
VITAL SIGNS:
Temperature: 98.5 °F, Pulse: 87, BP: 159/92 mmhg, RR 20, PO2-98% on room air, Ht- 6’4”, Wt 200 lb, BMI 25. Report pain 2/10.
GENERAL APPREARANCE
: The patient is aler.
Support with 1 journals no older than 5 years. H. Pylori infect.docx
Support with 1 journals no older than 5 years.
H. Pylori infection
Questions: As an NP student, needs to determine the medications for recurrent H. Pylori infection. According to the ACC/AHA Guidelines, what medication should this patient be prescribed? Write her complete prescriptions using the prescription writing format. ACC/AHA Guidelines Chief complaint: “ I have recurrent H. Pylori infection”. HPI: M.C. a 46-year-old hispanic female presents to the GI clinic for complaint of recurrent H. Pylori infection. She was treated about 2 ½ months ago with H. Pylori triple therapy and failed treatment. She has pmhx of dyspepsia, GERD. She also indicates that she has noticed that her symptoms of dyspepsia are worsening for past 2 months. She has associated her symptoms with nausea, upset stomach with all foods. Denies associated symptoms of hematochezia, melena, hemoptysis, abdominal pain, fever, chills, pain or any other symptoms. PMH: H. Pylori infection gastritis Diabetes Mellitus, type 2 Surgeries: None Allergies: NKDA Vaccination History: She receives an annual flu shot. Last flu shot was this year Social history: High school graduate, married and no children. He frequently eats out in restaurants. He drinks one 4-ounce glass of red wine daily. He is a former smoker that stopped 3 years ago. Family history: Both parents are alive. Father has history of DM type 2, Tinea Pedis. mother alive and has history of atopic dermatitis, tinea corporis and tinea pedis. ROS: Constitutional: Negative for fever. Negative for chills. Respiratory: No Shortness of breath. No Orthopnea Cardiovascular: No edema. No palpitations. Gastrointestinal: No vomiting. +Dyspepsia. + Nausea. No constipation. No melena. No abdominal pain. Skin: No lesions. No rash. No itching. Psychiatric: No anxiety. No depression. Physical examination: Vital Signs Height: 5 feet 5 inches Weight: 140 pounds BMI: 31 obesity, BP 110/70 T 98.0 po P 80 R 22, non-labored HEENT: Normocephalic/Atraumatic, PERRL, EOMI; No teeth loss seen. Gums no redness. NECK: Neck supple, no palpable masses, no lymphadenopathy, no thyroid enlargement. LUNGS: Lungs clear bilaterally. Equal breath sounds. Symmetrical respiration. No respiratory distress. HEART: Normal S1 with S2 during expiration. Pulses are 2+ in upper extremities. No edema. ABDOMEN: No abdominal distention. Nontender. Bowel sounds + x 4 quadrants. No organomegaly. Normal contour; No palpable masses. GENITOURINARY: No CVA tenderness bilaterally. GU exam deferred. MUSCULOSKELETAL: Slow gait but steady. No Kyphosis. SKIN: Dry. Intact. PSYCH: Normal affect. Cooperative. Labs day of visit:: Hgb 15.2, Hct 40%, K+ 4.0, Na+137, Serum Creatinine normal 1.0, AST/ALT normal. TSH 3.7 normal, glucose 98 normal A: Primary Diagnosis: Recurrent H. Pylori infection gastritis Secondary Diagnoses: Dyspepsia Differential Diagnosis: Peptic Ulcer Disease Previous medication plan: two month ...
Soap notes will be uploaded to Moodle and put through TURN-It-In (an
Soap notes will be uploaded to Moodle and put through TURN-It-In (anti-Plagiarism program)
Turn it in Score must be less than 50% or will not be accepted for credit, must be your own work and in your own words. You can resubmit, Final submission will be accepted if less than 50%. Copy paste from websites or textbooks will not be accepted or tolerated. Please see College Handbook with reference to Academic Misconduct Statement.
Example:
PATIENT INFORMATION
Name: Mr. W.S.
Age: 65-year-old
Sex: Male
Source: Patient
Allergies: None
Current Medications: Atorvastatin tab 20 mg, 1-tab PO at bedtime
PMH: Hypercholesterolemia
Immunizations: Influenza last 2018-year, tetanus, and hepatitis A and B 4 years ago.
Surgical History: Appendectomy 47 years ago.
Family History: Father- died 81 does not report information
Mother-alive, 88 years old, Diabetes Mellitus, HTN
Daughter-alive, 34 years old, healthy
Social Hx: No smoking history or illicit drug use, occasional alcoholic beverage consumption on social celebrations. Retired, widow, he lives alone.
SUBJECTIVE:
Chief complain
: “headaches” that started two weeks ago
Symptom analysis/HPI:
The patient is 65 years old male who complaining of episodes of headaches and on 3 different occasions blood pressure was measured, which was high (159/100, 158/98 and 160/100 respectively). Patient noticed the problem started two weeks ago and sometimes it is accompanied by dizziness.He states that he has been under stress in his workplace for the last month.
Patient denies chest pain, palpitation, shortness of breath, nausea or vomiting.
ROS:
CONSTITUTIONAL
: Denies fever or chills. Denies weakness or weight loss.
NEUROLOGIC
: Headache and dizzeness as describe above. Denies changes in LOC. Denies history of tremors or seizures.
HEENT
: HEAD: Denies any head injury, or change in LOC. Eyes: Denies any changes in vision, diplopia or blurred vision. Ear: Denies pain in the ears. Denies loss of hearing or drainage. Nose: Denies nasal drainage, congestion. THROAT: Denies throat or neck pain, hoarseness, difficulty swallowing.
Respiratory
:Patient denies shortness of breath, cough or hemoptysis.
Cardiovascular
: No chest pain, tachycardia. No orthopnea or paroxysmal nocturnal
dyspnea.
Gastrointestinal
:Denies abdominal pain or discomfort.Denies flatulence, nausea, vomiting or
diarrhea.
Genitourinary
: Denies hematuria, dysuria or change in urinary frequency. Denies difficulty starting/stopping stream of urine or incontinence.
MUSCULOSKELETAL
: Denies falls or pain. Denies hearing a clicking or snapping sound.
Skin
: No change of coloration such as cyanosis or jaundice, no rashes or pruritus.
Objective Data
CONSTITUTIONAL
: Vital signs: Temperature: 98.5 °F, Pulse: 87, BP: 159/92 mmhg, RR 20, PO2-98% on room air, Ht- 6’4”, Wt 200 lb, BMI 25. Report pain 0/10.
General appearance: The patient is alert and oriented x 3. No acute distress noted.
NEUROLOGIC:
Alert, CNII-XII grossly intac ...
Pulmonary Case PresentationsPlease select one case presentation be.docx
Pulmonary Case Presentations
Please select one case presentation below and provide answers to the following;
Three differential diagnoses
Definitive diagnosis
Management plan (include appropriate treatment/diagnostic tests)
Indications for referral and/or consultations (if needed)
Health education/lifespan considerations
Schedule a F/U appointment
Case I:
50 Y/O CM present with C/O dry cough x 4-5 months with 20 year H/O tobacco use of 1PPD for 20 years. Cough has become progressively worse over the past 2-3 weeks with yellow sputum production. Took OTC cough syrup without relief of symptoms. Afebrile at home. No CP or fatigue except with excessive coughing. No HAs or head injuries. No eye pain or drainage. No ear pain or difficulty hearing. Ocass. nasal drainage of clear mucus. No sore throat or difficulty swallowing. No neck pain or stiffness. Some SOB with excessive coughing. Excessive coughing interferes with ability to perform ADLs at times. No other household members with similar symptoms.
Temp--97.2
Pulse--94
B/P 140/90
RR- 24
Pulse Ox check-- 86% on Room Air
General: Alert, apprehensive but cooperative
SKIN: W/D with rapid recoil
HEENT: Normocephalic. PERRL, sclera clear, Bil. TMs pearly gray. Boggy, pale nasal mucosa. Oropharynx without erythema or exudate
NECK: Supple without LAD (lymphadenopathy)
HEART: Tachycardia without murmur, gallops or clicks
RESP: Distant lung sounds; positive rales at base with expiratory wheezes
Case II: (mom is present and is historian)
3 Y/O Asian male present with 3 day H/O dry cough that’s worse when playing outside near Spring flowers. Took OTC cough suppressant with cough resolved but reoccurred. Afebrile at home. Positive sneezing and itchy eyes at times. Consumes fluid and solid foods without difficulty. Mom reports tiring easily when outside playing with other children in neighborhood. No SOB noted per mom. Remain active and playful. No change in urinary habits with last BM this a.m, of soft brown consistency.
Temp--98.4
Pulse--104
B/P 80/68
RR- 26
Pulse Ox check-- 95%
General: Alert, cooperative without distress.
SKIN: W/D with rapid recoil
HEENT: Normocephalic. PERRL, sclera clear, Bil.TMs pearly gray. Boggy, pale nasal mucosa. O/P without erythema, masses, or lesions. Pink, moist mucous membranes.
NECK: Supple without LAD
HEART: Regular rate and rhythm (RRR) without murmur
RESP: Expiratory wheezing without retractions or nasal flaring
ABD: Soft, round, NT with positive BS
Case III:
J. V., a 24-year-old man, is admitted to the emergency department after a motorcycle accident. He is having trouble in breathing and is very upset. The rescue personnel tell you that his breath sounds are absent on the right side, his chest expands unequally, and that there is tracheal shift toward the left. There is a large contusion on his right rib cage.
Temp--97.2
Pulse--110
B/P 140/92
RR- 28
Pulse Ox check-- 88%
General: Alert & apprehensive
SKIN: Cool & diaphoretic; bluish discoloration to right anterior thorax.
Week 8GI Case Study H. Pylori infectionQuestions As an.docx
Week 8
GI Case Study: H. Pylori infection
Questions: As an NP student, needs to determine the medications for recurrent H. Pylori infection.
According to the ACC/AHA Guidelines, what medication should this patient be prescribed? Write her complete prescriptions using the prescription writing format.
ACC/AHA Guidelines
Chief complaint:
“ I have recurrent H. Pylori infection”.
HPI:
M.C. a 46-year-old hispanic female presents to the GI clinic for complaint of recurrent H. Pylori infection. She was treated about 2 ½ months ago with H. Pylori triple therapy and failed treatment. She has pmhx of dyspepsia, GERD.
She also indicates that she has noticed that her symptoms of dyspepsia are worsening for past 2 months. She has associated her symptoms with nausea, upset stomach with all foods.
Denies associated symptoms of hematochezia, melena, hemoptysis, abdominal pain, fever, chills, pain or any other symptoms.
PMH:
H. Pylori infection gastritis
Diabetes Mellitus, type 2
Surgeries: None
Allergies
:
NKDA
Vaccination History:
She receives an annual flu shot. Last flu shot was this year
Social history:
High school graduate, married and no children. He frequently eats out in restaurants. He drinks one 4-ounce glass of red wine daily. He is a former smoker that stopped 3 years ago.
Family history:
Both parents are alive. Father has history of DM type 2, Tinea Pedis.
mother alive and has history of atopic dermatitis, tinea corporis and tinea pedis.
ROS:
Constitutional: Negative for fever. Negative for chills.
Respiratory: No Shortness of breath. No Orthopnea
Cardiovascular: No edema. No palpitations.
Gastrointestinal: No vomiting. +Dyspepsia. + Nausea. No constipation. No melena. No abdominal pain.
Skin: No lesions. No rash. No itching.
Psychiatric: No anxiety. No depression.
Physical examination:
Vital Signs
Height: 5 feet 5 inches Weight: 140 pounds BMI: 31 obesity, BP 110/70 T 98.0 po P 80 R 22, non-labored
HEENT
: Normocephalic/Atraumatic, PERRL, EOMI; No teeth loss seen. Gums no redness.
NECK
: Neck supple, no palpable masses, no lymphadenopathy, no thyroid enlargement.
LUNGS
: Lungs clear bilaterally. Equal breath sounds. Symmetrical respiration. No respiratory distress.
HEART
: Normal S1 with S2 during expiration. Pulses are 2+ in upper extremities. No edema.
ABDOMEN
: No abdominal distention. Nontender. Bowel sounds + x 4 quadrants. No organomegaly. Normal contour; No palpable masses.
GENITOURINARY
: No CVA tenderness bilaterally. GU exam deferred.
MUSCULOSKELETAL
: Slow gait but steady. No Kyphosis.
SKIN:
Dry. Intact.
PSYCH
: Normal affect. Cooperative.
Labs day of visit
:: Hgb 15.2, Hct 40%, K+ 4.0, Na+137, Serum Creatinine normal 1.0, AST/ALT normal. TSH 3.7 normal, glucose 98 normal
A:
Primary Diagnosis: Recurrent H. Pylori infection gastritis
Secondary Diagnoses:
Dyspepsia
Differential Diagnosis:
Peptic Ulcer Disease
Previous medication plan:
two months ago and failed.
Clarithromycin 500 m ...
(Student Name) UniversityDate of EncounterPreceptorClini
(Student Name)
University
Date of Encounter:
Preceptor/Clinical Site:
Clinical Instructor:
Soap Note # Main Diagnosis ( Exp: Soap Note #3 DX: Hypertension)
PATIENT INFORMATION
Name: Mr. DT
Age: 68-year-old
Gender at Birth: Male
Gender Identity: Male
Source: Patient
Allergies: PCN, Iodine
Current Medications:
· Atorvastatin tab 20 mg, 1-tab PO at bedtime
· ASA 81mg po daily
· Multi-Vitamin Centrum Silver
PMH: Hypercholesterolemia
Immunizations: Influenza last 2018-year, tetanus, and hepatitis A and B 4 years ago.
Preventive Care: Coloscopy 5 years ago (Negative)
Surgical History: Appendectomy 47 years ago.
Family History: Father- died 81 does not report information
Mother-alive, 88 years old, Diabetes Mellitus, HTN
Daughter-alive, 34 years old, healthy
Social History: No smoking history or illicit drug use, occasional alcoholic beverage consumption on social celebrations. Retired, widow, he lives alone.
Sexual Orientation: Straight
Nutrition History: Diets off and on, Does not each seafood
Subjective Data:
Chief Complaint: “headaches” that started two weeks ago
Symptom analysis/HPI:
The patient is 65 years old male who complaining of episodes of headaches and on 3 different occasions blood pressure was measured, which was high (159/100, 158/98 and 160/100 respectively). Patient noticed the problem started two weeks ago and sometimes it is accompanied by dizziness. He states that he has been under stress in his workplace for the last month. Patient denies chest pain, palpitation, shortness of breath, nausea or vomiting.
Review of Systems (ROS)
CONSTITUTIONAL: Denies fever or chills. Denies weakness or weight loss. NEUROLOGIC: Headache and dizziness as describe above. Denies changes in LOC. Denies history of tremors or seizures.
HEENT: HEAD: Denies any head injury, or change in LOC. Eyes: Denies any changes in vision, diplopia or blurred vision. Ear: Denies pain in the ears. Denies loss of hearing or drainage. Nose: Denies nasal drainage, congestion. THROAT: Denies throat or neck pain, hoarseness, difficulty swallowing.
RESPIRATORY: Patient denies shortness of breath, cough or hemoptysis.
CARDIOVASCULAR: No chest pain, tachycardia. No orthopnea or paroxysmal nocturnal
dyspnea.
GASTROINTESTINAL: Denies abdominal pain or discomfort. Denies flatulence, nausea, vomiting or
diarrhea.
GENITOURINARY: Denies hematuria, dysuria or change in urinary frequency. Denies difficulty starting/stopping stream of urine or incontinence.
MUSCULOSKELETAL: Denies falls or pain. Denies hearing a clicking or snapping sound.
SKIN: No change of coloration such as cyanosis or jaundice, no rashes or pruritus.
Objective Data:
VITAL SIGNS: Temperature: 98.5 °F, Pulse: 87, BP: 159/92 mmhg, RR 20, PO2-98% on room air, Ht- 6’4”, Wt 200 lb, BMI 25. Report pain 2/10.
GENERAL APPREARANCE: The patient is alert and oriented x 3. No acute distress noted. NEUROLOGIC: Alert, CNII-XII grossly intact, oriented to person, ...
(Student Name) UniversityDate of EncounterPreceptorClini
1. The patient is a 68-year-old male who presented with headaches and high blood pressure readings over the past two weeks. On examination, his blood pressure was elevated at 159/92 mmHg.
2. The main diagnosis is essential (primary) hypertension given the symptoms and elevated blood pressure readings with no identifiable cause found. Differential diagnoses considered include renal artery stenosis, chronic kidney disease, and hyperthyroidism.
3. Labs, diagnostic tests, pharmacologic treatment with hydrochlorothiazide and lisinopril, and non-pharmacologic recommendations including lifestyle changes and follow up in 1 week are included in the treatment plan.
Knowledge of anatomy.docx
A 42-year-old African American male presents with lower back pain radiating to his left leg for the past month. Based on the patient's medical history and description of symptoms, the nerve roots involved could be L4, L5, or S1, which can be tested via straight leg raise test. Differential diagnoses include herniated disc, spinal stenosis, or sciatica. A physical exam and special maneuvers like straight leg raise test are needed to determine the cause and guide treatment.
case presentation respiratoy.pptx
Mrs. I.B, a 48 year old female, presented with complaints of recurrent cough for 1 year and breathlessness for 1 month, associated with hemoptysis, night sweats, and weight loss. She has a history of 3 previous treatments for pulmonary tuberculosis. On examination, she was in respiratory distress with clubbing and reduced breath sounds on the right lung. Investigations showed anemia, elevated ESR, and chest X-ray findings of post-TB changes. She was diagnosed with post-TB bronchiectasis exacerbated by chronic pulmonary aspergillosis.
Soap notes will be uploaded to Moodle and put through.docx
This soap note documents a visit for a 65-year-old male patient complaining of headaches for the past two weeks. On examination, the patient's blood pressure was elevated on multiple readings. The assessment is essential (primary) hypertension. The plan includes starting hydrochlorothiazide 25 mg daily, as well as lifestyle modifications and follow up with his primary care provider in one week to evaluate blood pressure control. No referrals are needed at this time.
Support with 1 journals no older than 5 years.Week 8GI Case .docx
Support with 1 journals no older than 5 years.
Week 8
GI Case Study: H. Pylori infection
Questions: As an NP student, needs to determine the medications for recurrent H. Pylori infection.
According to the ACC/AHA Guidelines, what medication should this patient be prescribed? Write her complete prescriptions using the prescription writing format.
ACC/AHA Guidelines
Chief complaint:
“ I have recurrent H. Pylori infection”.
HPI:
M.C. a 46-year-old hispanic female presents to the GI clinic for complaint of recurrent H. Pylori infection. She was treated about 2 ½ months ago with H. Pylori triple therapy and failed treatment. She has pmhx of dyspepsia, GERD.
She also indicates that she has noticed that her symptoms of dyspepsia are worsening for past 2 months. She has associated her symptoms with nausea, upset stomach with all foods.
Denies associated symptoms of hematochezia, melena, hemoptysis, abdominal pain, fever, chills, pain or any other symptoms.
PMH:
H. Pylori infection gastritis
Diabetes Mellitus, type 2
Surgeries: None
Allergies
:
NKDA
Vaccination History:
She receives an annual flu shot. Last flu shot was this year
Social history:
High school graduate, married and no children. He frequently eats out in restaurants. He drinks one 4-ounce glass of red wine daily. He is a former smoker that stopped 3 years ago.
Family history:
Both parents are alive. Father has history of DM type 2, Tinea Pedis.
mother alive and has history of atopic dermatitis, tinea corporis and tinea pedis.
ROS:
Constitutional: Negative for fever. Negative for chills.
Respiratory: No Shortness of breath. No Orthopnea
Cardiovascular: No edema. No palpitations.
Gastrointestinal: No vomiting. +Dyspepsia. + Nausea. No constipation. No melena. No abdominal pain.
Skin: No lesions. No rash. No itching.
Psychiatric: No anxiety. No depression.
Physical examination:
Vital Signs
Height: 5 feet 5 inches Weight: 140 pounds BMI: 31 obesity, BP 110/70 T 98.0 po P 80 R 22, non-labored
HEENT
: Normocephalic/Atraumatic, PERRL, EOMI; No teeth loss seen. Gums no redness.
NECK
: Neck supple, no palpable masses, no lymphadenopathy, no thyroid enlargement.
LUNGS
: Lungs clear bilaterally. Equal breath sounds. Symmetrical respiration. No respiratory distress.
HEART
: Normal S1 with S2 during expiration. Pulses are 2+ in upper extremities. No edema.
ABDOMEN
: No abdominal distention. Nontender. Bowel sounds + x 4 quadrants. No organomegaly. Normal contour; No palpable masses.
GENITOURINARY
: No CVA tenderness bilaterally. GU exam deferred.
MUSCULOSKELETAL
: Slow gait but steady. No Kyphosis.
SKIN:
Dry. Intact.
PSYCH
: Normal affect. Cooperative.
Labs day of visit
:: Hgb 15.2, Hct 40%, K+ 4.0, Na+137, Serum Creatinine normal 1.0, AST/ALT normal. TSH 3.7 normal, glucose 98 normal
A:
Primary Diagnosis: Recurrent H. Pylori infection gastritis
Secondary Diagnoses:
Dyspepsia
Differential Diagnosis:
Peptic Ulcer Disease
Previous medic ...
SOAP NOTEName J.D.Date 03262020Time 200 pmAge 25 .docx
SOAP NOTE
Name: J.D.
Date: 03/26/2020
Time: 2:00 pm
Age: 25 y/o
Sex: F
SUBJECTIVE
CC:
” I have a lot of pain on my left side, in my lower belly”
HPI: J.D. is a 25-year-old white female that came to the office today complaining of pain in her lower abdomen. The patient has always had painful cramps with her periods but this time it is much worse being described as a 6 out of 10 and lasting up to 5 hours. The pain started 2 days ago. The pain is described as more painful cramps. It is debilitating and prevents the patient from performing most daily activities. It is localized in the lower abdominal area, and sometimes radiates down her legs, and to her lower back. The patient uses hot compresses to relieve the pain as Tylenol does not work. The patient also states that she has been feeling nauseous ever since the pain started. She also urinates more frequently and pain on urination. Denies fever, vomiting, or chills.
Medications:
2 Tylenol as needed for her pain
PMH (include-immunization status including Gardisil, GTPLA).
Current or past illnesses: No current or past illnesses
Immunizations: All vaccines updated including flu vaccine and Gardasil.
Allergies: NKDA
Medication Intolerances: None.
Chronic Illnesses/Major traumas: None.
Hospitalizations/Surgeries (include delivery of pregnancies here)
No hospitalizations.
G0P0
Family History
Mother: 49 years old, no significant health problems
Maternal Side: No significant health problems
Father: 50 years old, hypertensive
Paternal Side: no significant health problems
Social History
Patient works full-time as a research assistant at a local university. A full-time student seeking a master’s degree in biochemistry at a local university. Married. Sexually active only with husband. Always uses male condoms as contraceptive device. Does not use recreational drugs, tobacco, or electronic cigarettes. Devout follower of Christianity. Denomination: catholic.
ROS
General Patient denies fever or chills, no weight changes.
Cardiovascular Denies chest pain, or discomfort. Denies palpitations, dyspnea, or orthopnea.
Skin: Denies presences of moles, rash, or itching.
Respiratory: Denies dyspnea, cough, hemoptysis, or pleuritic pains.
Eyes Denies problems or changes in her vision; denies double or blurred vision.
Gastrointestinal Positive for nausea.Denies hemorrhoids, constipation, or diarrhea. No variation in bowel habits. Denies vomiting.
Ears Denies difficulty or changes in his hearing. Denies tinnitus, or discharges.
Genitourinary/Gynecological Menarche 11 years old. Regular menstrual periods starting around the 3rd week of every month. LMP: 03.
Soap notes will be uploaded to Moodle and put through TURN-It-In (anti.docx
Soap notes will be uploaded to Moodle and put through TURN-It-In (anti-Plagiarism program)
Turn it in Score must be less than 50% or will not be accepted for credit, must be your own work and in your own words. You can resubmit, Final submission will be accepted if less than 50%. Copy paste from
websites
or textbooks will not be accepted or tolerated. Please see College Handbook with reference to Academic Misconduct Statement.
Example:
PATIENT INFORMATION
Name: Mr. W.S.
Age: 65-year-old
Sex: Male
Source: Patient
Allergies: None
Current Medications: Atorvastatin tab 20 mg, 1-tab PO at bedtime
PMH: Hypercholesterolemia
Immunizations: Influenza last 2018-year, tetanus, and hepatitis A and B 4 years ago.
Surgical History: Appendectomy 47 years ago.
Family History: Father- died 81 does not report information
Mother-alive, 88 years old, Diabetes Mellitus, HTN
Daughter-alive, 34 years old, healthy
Social Hx: No smoking history or illicit drug use, occasional alcoholic beverage consumption on social celebrations. Retired, widow, he lives alone.
SUBJECTIVE:
Chief complain
: “headaches†that started two weeks ago
Symptom analysis/HPI:
The patient is 65 years old male who complaining of episodes of headaches and on 3 different occasions blood pressure was measured, which was high (159/100, 158/98 and 160/100 respectively). Patient noticed the problem started two weeks ago and sometimes it is accompanied by dizziness. He states that he has been under stress in his workplace for the last month.
Patient denies chest pain, palpitation, shortness of breath, nausea or vomiting.
ROS:
CONSTITUTIONAL
: Denies fever or chills. Denies weakness or weight loss.
NEUROLOGIC
: Headache and dizziness as describe above. Denies changes in LOC. Denies history of tremors or seizures.
HEENT
: HEAD: Denies any head injury, or change in LOC. Eyes: Denies any changes in vision, diplopia or blurred vision. Ear: Denies pain in the ears. Denies loss of hearing or drainage. Nose: Denies nasal drainage, congestion. THROAT: Denies throat or neck pain, hoarseness, difficulty swallowing.
Respiratory
: Patient denies shortness of breath, cough or hemoptysis.
Cardiovascular
: No chest pain, tachycardia. No orthopnea or paroxysmal nocturnal
dyspnea.
Gastrointestinal
: Denies abdominal pain or discomfort. Denies flatulence, nausea, vomiting or
diarrhea.
Genitourinary
: Denies hematuria, dysuria or change in urinary frequency. Denies difficulty starting/stopping stream of urine or incontinence.
MUSCULOSKELETAL
: Denies falls or pain. Denies hearing a clicking or snapping sound.
Skin
: No change of coloration such as cyanosis or jaundice, no rashes or pruritus.
Objective Data
CONSTITUTIONAL
: Vital signs: Temperature: 98.5 °F, Pulse: 87, BP: 159/92 mmhg, RR 20, PO2-98% on room air, Ht- 6’4â€, Wt 200 lb, BMI 25. Report pain 0/10.
General appearance: The patient is alert and oriented x 3. No acute dist.
62181184 quinx-case-study
Mrs. A, a 76-year-old woman with a history of hypertension and stroke, presented with body weakness. Her physical exam found weakness on her right side and enlarged heart on chest x-ray. Lab results showed abnormal cholesterol and electrolyte levels. She was diagnosed with uncontrolled hypertension and given medications to control her blood pressure along with dietary and lifestyle counseling upon discharge.
Case StudyChief complaint I’m here for a medication refill .docx
Case Study:
Chief complaint:
“I’m here for a medication refill because I ran out of my medicines”.
HPI:
Mrs. Allen is a 68-year-old African American who presents to the clinic for prescription refills. The patient indicates that she has noticed shortness of breath which started about 3 months ago. The SOB gets worse with exertion, especially when she is walking fast, and it is resolved when she is resting. She reports that she is also bothered by shortness of breath that wakes her up intermittently during her sleep. Her symptoms of shortness of breath resolve after sitting upright on 3 pillows. She also has lower leg edema pitting 1+ which started 2 weeks ago. She indicates that she often feels light headed at times with intermittent syncope episodes while going up a flight of stairs, but it resolves after sitting down to rest. She has not tried any over the counter medications at home.
She started taking her medications, but failed to refill the prescriptions because she cannot afford the medications as she only works part-time and lives alone. In addition, she reports that she does not think taking all these medications would help her condition anyway.
PMH:
Primary Hypertension, Previous history of MI 1 year ago
Surgeries:
1 year ago-Left Anterior Descending (LAD) cardiac stent placement
Allergies
:
Penicillin
Vaccination History:
Up-to-date
Social history:
High school graduate married and no children. Drinks one 4-ounce glass of red wine daily. She is a former smoker and stopped 5 years ago.
Family history:
Both parents are alive. Father has history of MI and valvular heart disease; mother alive and cardiac history is unknown. He has one brother who is alive and has history of MI 5 years ago at age 52.
ROS:
Constitutional: Lightheaded and faint with exertion. Respiratory: Shortness of breath with exertion. + Orthopnea. Cardiovascular: + 2 pitting leg edema for 3 weeks.
Psychiatric: Non-contributory.
Physical examination:
Vital Signs:
Height: 5 feet 1 inches Weight: 175 pounds BMI: 32, Obese, BP 160/92, T 98.0, P 111, R 22 and non-labored
HEENT
: Normocephalic/Atraumatic, Bilateral cataracts; PERRLA, EOMI; Teeth intact. Negative for gum disease.
NECK
: Neck supple, no palpable masses, no lymphadenopathy, no thyroid enlargement.
LUNGS
: + Mild Crackles on inspiratory phase not clearing with cough. Equal breath sounds. Symmetrical respiration. No respiratory distress.
HEART
: Normal S1 with S2 during expiration. An S4 is noted at the apex; + systolic murmur noted at the right upper sternal border without radiation to the carotids. Pulses are 2+ in upper extremities and 2+ in pedal pulses bilaterally. 2+ pitting edema to her knees noted bilaterally.
ABDOMEN
: No abdominal distention. Nontender. Bowel sounds + x 4 quadrants. No organomegaly. Normal contour; No palpable masses.
GENITOURINARY
: No CVA tenderness bilaterally. GU exam deferred.
MUSCULOSKELETAL
: + Heberden's nodes at the DIP joints, hands. + Crepi.
Give an example from your own experience or research an article or.docx
Give an example from your own experience or research an article or the media in which a business executive did something of significance that is morally right. Use APA format to cite your material from your sources.
Is there a relationship between obesity and socio-economic status? Should obese people be considered a protected class under Title VII of the Civil Rights Act?
1:
2:
3.
4.
5.
Comprehensive SOAP Exemplar
Purpose: To demonstrate what each section of the SOAP Note should include. Remember that nurse practitioners treat patients in a holistic manner, and your SOAP Note should reflect that premise.
Patient Initials: _______
Age: _______
Gender: _______
SUBJECTIVE DATA:
Chief Complaint (CC): Coughing up phlegm and fever
History of Present Illness (HPI): Sara Jones is a 65-year-old Caucasian female who presents today with a productive cough x 3 weeks and fever for the last 3 days. She reported that the “cold feels like it is descending into her chest.” The cough is nagging and productive. She brought in a few paper towels with expectorated phlegm – yellow/brown in color. She has associated symptoms of dyspnea of exertion and fever. Her Tmax was reported to be 102.4 last night. She has been taking Ibuprofen 400mg about every 6 hours and the fever breaks, but it returns after the medication wears off. She rated the severity of her symptom discomfort at 4/10.
Medications:
1.) Lisinopril 10mg daily
2.) Combivent 2 puffs every 6 hours as needed
3.) Serovent daily
4.) Salmeterol daily
5.) Over-the-counter Ibuprofen 200mg -2 PO as needed
6.) Over-the-counter Benefiber
7.) Flonase 1 spray each night as needed for allergic rhinitis symptoms
Allergies:
Sulfa drugs - rash
Past Medical History (PMH):
1.) Emphysema with recent exacerbation 1 month ago – deferred admission – RX’d with outpatient antibiotics and hand held nebulizer treatments.
2.) Hypertension – well controlled
3.) Gastroesophageal reflux (GERD) – quiet, on no medication
4.) Osteopenia
5.) Allergic rhinitis
Past Surgical History (PSH):
1.) Cholecystectomy 1994
2.) Total abdominal hysterectomy (TAH) 1998
Sexual/Reproductive History:
Heterosexual
G1P1A0
Non-menstruating – TAH 1998
Personal/Social History:
She has smoked 2 packs of cigarettes daily x 30 years; denied ETOH or illicit drug use.
Immunization History:
Her immunizations are up to date. She received the influenza vaccine last November and the Pneumococcal vaccine at the same time.
Significant Family History:
Two brothers – one with diabetes, dx at age 65, and the other with prostate CA, dx at age 62. She has one daughter in her 30s, healthy, living in nearby neighborhood.
Lifestyle:
She is retired, has been widowed x 8 years, and lives in the city in a moderate crime area with good public transportation. She is a college graduate, owns her home, and receives a pension of $50,000 annually – financially stable.
She has a primary care nurse practitioner provider and goes for annual and r ...
Hypertension
This document presents a case study of a 47-year-old female patient named Mrs. Dhakshayani who is being treated for hypertension. She has been taking medication for hypertension for 1 year. On examination, her blood pressure was found to be 178/90 mmHg, indicating stage 2 hypertension. She has a family history of hypertension in her husband. Her diet lacks vegetables and fruits. The provisional diagnosis is stage 2 hypertension. The goals are to reduce her weight by 5-7 kg through a low sodium, low fat diet and increased physical activity, and to bring her blood pressure under control through regular medical checkups and medication compliance.
Similar to Hypertension Case StudyC.D is a 55-year-old African American male (20)
Sample Soap NoteSoap Note # Main Diagnosis ( Exp H&P Note .docx
Sample Soap NoteSoap Note # Main Diagnosis ( Exp H&P Note .docx
Soap Note # Main Diagnosis ( Exp H&P Note #3 DX Hypertension).docx
Soap Note # Main Diagnosis ( Exp H&P Note #3 DX Hypertension).docx
Support with 1 journals no older than 5 years. H. Pylori infect.docx
Support with 1 journals no older than 5 years. H. Pylori infect.docx
Soap notes will be uploaded to Moodle and put through TURN-It-In (an
Soap notes will be uploaded to Moodle and put through TURN-It-In (an
Pulmonary Case PresentationsPlease select one case presentation be.docx
Pulmonary Case PresentationsPlease select one case presentation be.docx
Week 8GI Case Study H. Pylori infectionQuestions As an.docx
Week 8GI Case Study H. Pylori infectionQuestions As an.docx
(Student Name) UniversityDate of EncounterPreceptorClini
(Student Name) UniversityDate of EncounterPreceptorClini
(Student Name) UniversityDate of EncounterPreceptorClini
(Student Name) UniversityDate of EncounterPreceptorClini
Soap notes will be uploaded to Moodle and put through.docx
Soap notes will be uploaded to Moodle and put through.docx
Support with 1 journals no older than 5 years.Week 8GI Case .docx
Support with 1 journals no older than 5 years.Week 8GI Case .docx
SOAP NOTEName J.D.Date 03262020Time 200 pmAge 25 .docx
SOAP NOTEName J.D.Date 03262020Time 200 pmAge 25 .docx
Soap notes will be uploaded to Moodle and put through TURN-It-In (anti.docx
Soap notes will be uploaded to Moodle and put through TURN-It-In (anti.docx
Case StudyChief complaint I’m here for a medication refill .docx
Case StudyChief complaint I’m here for a medication refill .docx
Give an example from your own experience or research an article or.docx
Give an example from your own experience or research an article or.docx
More from eve2xjazwa
Discussion 1Choose any four ‘causes’ of change within a projec.docx
Discussion 1
Choose any four ‘causes’ of change within a project in table 9.1 in the text. Provide a project example and scenario, and describe the impact of each change. Was there a level of change control in the project examples that tracked ownership, documentation and approval of these changes?
Discussion 2
The identification of all changes to a project is only the first step for ensuring a control system is in place. Describe the detailed steps you would implement for your project to ensure an entire change control process is in place. Consider the following topics in your answer: documentation, analysis, approval and implementation. Why is the baseline configuration important to this topic?
.
DISCUSSION 1Community and Health Information Networks Please .docx
A key trend supporting CHINs and RHINOs is increased data sharing across organizations to improve care coordination. Transitioning from CHINs to RHINOs has more benefits than challenges as it allows for broader sharing of health information across larger regions. Integrating CPOE and CDSS into EHRs has the advantage of catching errors and providing treatment recommendations to improve patient safety and outcomes. Electronic database systems are more efficient than paper records as they reduce errors, save space, and allow easy access to records. The main advantages of EMRs are reduced errors, easy sharing of information, and improved treatment while the disadvantages include costs of implementation and concerns about privacy and security.
Discussion 10 Concluding the SemesterPurposeThis assignment is .docx
Discussion 10: Concluding the Semester
Purpose
This assignment is closely tied to specific course objectives. Two of the major primary course objectives of CST 100 are that students show respect for ethical codes that govern spoken discourse, such as tolerance for differences of opinion, preference for civility and that students will demonstrate increased understanding and appreciation of the communication process as it relates to speaker and listener interactions. By completing this assignment students will reflect on the things they learned and articulate important lasting lessons of public speaking.
Directions
Part 1: Initial Post
Find the due date for this part on the course calendar.
As we conclude the semester, reflect on some of the things that you learned about public speaking and your growth as a communicator throughout the semester.
In a 3-4 paragraph posting, address the four items below
What are the most important areas of personal growth that you have experienced as a communicator? Identify personal insights and communication competencies that are part of that growth.
What are some of the most useful theories and concepts that we examined in the class?
How can you apply some of the things that you learned during the semester to your professional life and to your current or future work?
What aspects of communication do you want to learn more about?
.
Discussion 1 Social Security and Social Welfare ProgramsFor years.docx
Discussion 1: Social Security and Social Welfare Programs
For years, many working individuals in the United States have counted on Social Security as their primary retirement income. With the deductions from every paycheck to fund this future benefit, Americans looked forward to a comfortable retirement based on the assumption that these funds were being invested wisely. Is this a factual assumption, or is it another myth of the U.S. social welfare system?
Relying on Social Security as a sole means of support in retirement is uncommon. As society’s work habits and life expectancies change, Social Security has come to mean different things to different people. For those who are unable to save and/or invest on their own, it functions like a forced retirement program that provides a financial safety net for the future. For those who become unable to work, social security often is viewed by others as a public assistance program. For others who are financially secure and prepared for retirement, it is an entitlement program where individuals draw Social Security at retirement in an effort to recoup what they paid into the program by deductions from their wages. How might these perceptions of Social Security relate to the perceptions of public assistance programs that were discussed in last week’s resources?
For this Discussion,
review this week’s resources. Then, consider how Social Security is different from public assistance programs. Finally, think about how these differences are important in terms of the general perception of Social Security benefits.
Post by Day 3
an explanation of how Social Security is different from public assistance programs. Then, explain how these differences are important, in terms of the general perception of Social Security benefits.
Support your post with specific references to the resources. Be sure to provide full APA citations for your references.
.
Discussion 1 Religion and Privilege For citizens in some countrie.docx
Discussion 1: Religion and Privilege
For citizens in some countries, religious oppression is common and long standing. While freedom of religion is guaranteed in the U.S., religious intolerance still exists. According to the Equal Opportunity Employment commission, the number of lawsuits filed for religious discrimination doubled between 2000–2010 (Pledger, 2011). Social workers must be alert for the complex ways that religious privilege functions. By creating an awareness of the privilege given to some while marginalizing others, social workers can understand how this bias impacts their clients.
Post an explanation of the connections between privilege and religion.
Describe a situation in which members of a religion experience privilege.
Describe a situation in which members of a religion experience religious oppression
.
References (use at least 2)
Adams, M., Blumenfeld, W. J., Castaneda, C., Hackman, H. W., Peters, M. L., & Zuniga, X. (Eds.). (2013).
Readings for diversity and social justice
. (3rd ed.). New York, NY: Routledge Press.
Chapter 43, (pp. 237–242)
Chapter 44, (pp. 243–244)
Discussion 2: Self-Assessment
Competent social workers have many traits and characteristics, one of which is the ability to be self-reflective. The best way to begin critically thinking about the impact of ethnocentrism and racism is to start with oneself. How do these issues affect you? For this Discussion, think about when and how you became aware of your own racial identity and consider how this awareness has impacted your life.
Post an explanation of a time in your childhood when you became aware of your own racial identity (African American).
Be sure to include a description of how this newfound awareness impacted both your development and views of difference.
Please use the Learning Resources to support your answer.
References (use at least 2)
Cristol, D., & Gimbert, B. (2008). Racial perceptions of young children: A review of literature post-1999.
Early Childhood Education Journal, 36
(2), 201–207.
Patcher, L. M., Szalacha, L. A., Bernstein, B., & Garcia Coil, C. (2010). Perceptions of racism in children and youth: Properties as a self-report instrument for research on children’s health and development.
Ethnicity & Health, 15
(1), 33–46.
Zastrow, C. H., & Kirst-Ashman, K. K. (2016).
Understanding human behavior and the social environment
(10th ed.)
.
Boston, MA: Cengage Learning.
Chapter 5 (pp. 254-294)
.
Discussion 1 Social and Economic JusticeThe Center for Economic a.docx
Discussion 1: Social and Economic Justice
The Center for Economic and Social Justice defines “social justice” as “giving to each what he or she is due.” “Economic justice” is concerned with determining what an individual’s “due” actually encompasses.
For this Discussion, select a case study in this week’s Readings. Review the case study, focusing on the social or economic justice issues at play in the situation described.
***Post
a description of a social or economic justice issue that is evident in the case. Suggest two strategies the social worker might employ to address the issue.
Reference: Center for Economic and Social Justice. (n.d.).
Defining economic justice and social justice
. Retrieved from June 11, 2013, from
http://www.cesj.org/thirdway/economicjustice-defined.htm
CASE STUDY:
Working With Survivors of Sexual Abuse and Trauma: The Case of Brenna
Brenna is an 18-year-old, heterosexual, African American female. She is pregnant, residing in a homeless shelter, and has no income source. Brenna was raised by her biological mother in a one-bedroom apartment in an urban neighborhood. When Brenna was 15 years old, her mother began dating a new man. This man sexually assaulted Brenna while they were home alone one evening. She immediately disclosed the sexual assault to her mother who called her a liar and told her to move out. Brenna then lived in a variety of situations, sometimes residing with friends for short periods and sometimes living in a youth shelter. During this period she attended high school intermittently but did not graduate.
After her 18th birthday, Brenna moved in with her boyfriend, Cameron. Also living in the household were Cameron’s mother, his 16-year-old sister, and a 7-year-old brother. Shortly after moving in with Cameron, Brenna became pregnant with his child. Prior to the pregnancy, Cameron would often abuse her physically, verbally, and emotionally. When Brenna announced the pregnancy, Cameron became even more violent, accused her of sleeping with other men, and denied paternity of the baby. When Brenna was 4 months pregnant, Cameron attempted to strangle her, so Brenna moved to a shelter. Although the shelter was willing to house Brenna and her newborn temporarily, their policy required Brenna to secure new living arrangements prior to giving birth.
I was assigned to be Brenna’s social work case manager at this shelter. Brenna and I worked together to set manageable goals during her stay at the shelter and also developed a plan for ongoing mental health support. Utilizing individual case manage- ment sessions, I worked with Brenna to prioritize goals regarding nancial stability, permanent housing, and medical care. Brenna had dif culty reading and writing, so we worked together to
PRACTICE
31
SOCIAL WORK CASE STUDIES: FOUNDATION YEAR
complete the applications for Medicaid; General Assistance; the Supplemental Nutrition Program for Women, Infants, and Chil- dren (WIC); and a local subsidized apartment.
Discussion 1Challenging BehaviorAfter reading Chapter 1 of t.docx
Discussion 1
Challenging Behavior
After reading Chapter 1 of the course text, write a response to the following question:
At what point does behavior become challenging? Include at least 3 examples of challenging behavior that are commonly seen in young children. Cite at least one source, in addition to course text, to substantiate your response.
(Due: Thursday 10/13)
Discussion 2
The Resilient Child
After reading Chapter 3 of the course text, write a response to the following question:
Why is it important for early childhood educators to have an understanding of resiliency? How could knowledge of a child’s risk and protective factors change your attitude and your behavior toward a child or her family?
(Due: Thursday 10/13)
Discussion 1 and 2 needs to be done separately... Please DO NOT put them on the same paper.
.
Discussion 1 Sara Parker and EthicsOne of the reasons there can.docx
Discussion 1: Sara Parker and Ethics
One of the reasons there can be so much debate about ethical issues is because ethics are opinions informed by people's values and people have different values. People can disagree about whether or not something is unethical, and, oftentimes, there is no right answer. In order to make decisions about what may be ethical or unethical, Yegidis (2012, p. 29) suggests focusing on these three questions:
"Who should benefit or suffer from the actions of the researcher?"
"Whose rights should take priority over those of others?"
"Does the end (increased knowledge) justify the means (the methods used to acquire it and their potential for harm)?"
For this Discussion, view the Sessions episode on the Parker family. As you do so, consider which, if any, ethical mandates or standards were violated.
·
Post
a response explaining your reaction to the Parker episode.
·
Be sure to address whether or not the social worker violated any ethical mandates or standards.
·
Also explain which strategies could have been used to guide ethical practice.
·
Finally, describe the responsibility of the social workers in the Parker case.
Please use the resources to support your answers.
References
Laureate Education. (Producer). (2013).
Parker Family [Video File]
. In Sessions.
Labott, S. M., & Johnson, T. P. (2004). Psychological and social risks of behavioral research. IRB: Ethics & Human Research, 26(3), 11–15.
Nicotera, N., & Walls, N. E. (2010). Challenging perceptions of academic research as bias free: Promoting a social justice framework in social work research methods courses. Journal of Teaching in Social Work, 30(3), 334–350.
Parker Family Episode 4
Program Transcript
SOCIAL WORKER: Well, I think we should wrap things up. Does this same time
work for you next week?
SARA: Yes, it's fine.
SOCIAL WORKER: Let me give you an appointment card. By the way, something occurred to me that might interest you. I have a colleague that's doing a study on the impact of hoarding on family members. She wants to identify potential interventions. I think she'd love to talk to you and Stephanie.
SARA: Talk to me?
SOCIAL WORKER: She's paying participants in her study. I don't know how much.
SARA: Do I have to do it? I-- I just don't like people knowing my business.
SOCIAL WORKER: It's totally confidential and anonymous.
SARA: I don't know.
SOCIAL WORKER: I think it'd be a great opportunity for you.
SARA: I don't know. Would she have to come see my home? I mean, I don't like people seeing how I live.
SOCIAL WORKER: Don't worry about that. You should at least talk to her. Like I
said, there's some money in it for you. Can I give her your number?
THE END
Discussion 2: The Research Approval Process
The early years of the 20th century were host to a number of unethical research studies. Research involving the way that a young child reacts to and generalizes fear responses, medical experiments conducted i.
Discussion 1 Reflections on Qualitative Research for Social Change.docx
Discussion 1: Reflections on Qualitative Research for Social Change
Introduction: Social Change
In the recent years, the pursuit for institutions, “practical researchers” and individuals to join in the crusade for
social change
has been remarkable; as many people around the world are reaching out to their neighborhoods as a member of the community to contribute to the common good through research, service, and educational opportunities (
Yob
& Brewer, 2015. p.2). Social change constitutes a change in the nature, the social institutions, the social behavior or the social relations of a society, community of people, or other social structures (Walden University, 2016). Social change can be at the micro scale (that positively shape values, attitudes and behaviors) or at the macro scale (that positively shape
economies, religion and families).
The Essence of Social Change to a Walden Student
Yob
& Brewer (2015) observed that the term “social change” has been defined and analyzed across the academic disciplines, reflecting the particular perspective of that discipline and its research agenda. Prominent among the definition of
social change
are the concepts of
social justice
and
equity
which have been significant in discussions of social change in education, psychology, and social and cultural studies (Curry-Stevens, 2007; Drury &
Reicher
, 2009;
Moely
,
Furco
, & Reed, 2008; and
Peterson, 2009, as were cited in
Yob
& Brewer (2015). There are as many definitions for
social change
as we have social scientists. However
Hoff and
Hickling
-Hudson (2011), supporting the definition of
Aloni
(2002), provided the definition which places social change as “challenging trends of discrimination, exploitation, oppression, and subjugation displayed by groups who regard themselves as favored and, thus, take privileges for themselves and deprive other groups of the right to a dignified life” (p. 189). In this context, “
change”
as is used in the “social change” is defined here in positive and value-laden terms that relate more particularly to the agents of social change than to others they might want to change.
There is a great range and variation in the roles and positions that researchers takes up in research, as was observed by
Ravitch
& Carl (2016).
Over the years (
more than 45 years), Walden University has produced career professionals with the opportunity to transform themselves as scholar-practitioners so that they can apply what
they’ve
learned to effect positive social change. Walden is focused on inspiring and celebrating the remarkable achievements of community members who continue to make a difference by addressing challenges where they live, in their professions, and in the world around them. This was a major factor that attracted me to pursue a
programme
at Walden. In our sub-region, (the sub-Sahara Africa), addressing the issue of social change from the national perspective has not been as significant relative to the.
Discussion 1As of my experience and observations mainly there ar.docx
Discussion 1
As of my experience and observations mainly there are Two key themes in contemporary information systems development there are First one is: how to build and issue systems in tinier time settings second one is: how to empower development clusters to build systems in a consistent manner. This is reflected in present days’ principal fashionable this information system development methods such as nimble, their characteristic feature being an unambiguous prominence on unremitting, appropriate proclamations and a simplification of operative cluster association and announcement. As of my experience and observations most of the software developers we reconnoitre the personal property of cluster consistency and two categories of time pressure, deterrent and challenge, on the decision-making eminence of system development clusters. The challenge time pressure and cluster consistency to have a optimistic consequence with interruption time pressure having no substantial influence.
As well working composed in a consistent cluster, petite, system development cycles mean that Software Development clusters obligation similarly work under fluctuating gradations of time pressure. Most studies in this field of information systems development and software development on time pressure measure time as a rectilinear hypothesis and enumerate it in terms of time ancient history. In this Developments I observed One of the major matters with these revisions nevertheless is that they frequently harvest contradictory consequences and as hitherto, there is no any approved and comprehensive hypothetical empathetic of the time pressure hypothesis.
In my experience, I would like to share one example, some outcomes recommend that software development clusters achieve improved under time pressure. So far others recommend that clusters accomplish improved up to a convinced argument after which presentation deteriorations, important to the generally recognized reversed-U model. It is clear that time pressure is a multipart hypothesis and while typically scrutinized as a linear hypothesis, nonlinear associations are conceivable. With a present prominence in information system development and in particular software development on clusters conclusion production in pressurized environments it is domineering that investigators endure to gain larger empathetic of the anthropological behavioural characteristic of the decision-making development. Sympathetic how clusters work composed under time pressure is a key goal in development system and its essential to entirely appreciate this complication and help comprehend accurately how and if time pressure and consistency influence of software development clusters.
Seeming Time Pressure in Teams
Time pressure is abstractly diverse from insistence. Perseverance is a unchanging peculiarity that reproduces a anxiety for time and a feeling of being recurrently pressurized In disparity, time pressure is an assessment of the task si.
Discussion 1Body Image Please respond to the followingDebate.docx
Discussion 1:
"Body Image" Please respond to the following:
Debate It – take a position on this statement: Media cause individuals to develop negative and unrealistic body images. Support your views with two or three reasons and / or examples. (Cite any sources you referenced.)
Debate It – take a position on this statement: Males and females are both targeted about body image to the same extent by advertisers. Support your views with one or two reasons and / or examples. (Cite any sources you referenced.)
Discussion 2:
"Do Video Games Encourage Sexist Behavior?" Please respond to the following:
Discuss one or two conflicting issues involving the view that video games encourage sexist behavior.
Debate It – Take a position on this statement: Violent video games encourage sexist behavior in adolescent and adult men. Support your views with two or three reasons and / or examples. (Cite any sources you referenced.)
.
Discussion 1 Influence of Classical Democratic TheoristsSince anc.docx
Discussion 1: Influence of Classical Democratic Theorists
Since ancient times, the idea of how people should govern has been a mainstay of philosophers and political theorists. One of the most enduring notions to emerge from early theorists is the basic belief that people are capable of governing themselves. The concept of democratic governance developed out of those early intellectual discussions. Democratic governance enjoys widespread acceptance in many parts of the world today. Yet, the exact meaning of democratic governance and how it should be implemented still remains a topic of debate. Democratic theory has evolved because of contributions from classical democratic theorists such as Aristotle, Plato, Rousseau, Locke, and Jefferson. It is important to consider of the ideas of these classical theorists when thinking about modern democratic theory.
To prepare for this Discussion
Review the Course Introduction. Keep this overview in mind as you work through each week of the course.
Review the article “American Nightmare: Neoliberalism, Neoconservatism, and De-Democratization” in this week’s Learning Resources. Think about the effects of political democratic theories on contemporary democracy.
Review the article “Rhetoric and the Public Sphere: Has Deliberative Democracy Abandoned Mass Democracy?” in this week’s Learning Resources. Consider how Plato’s theory of deliberative democracy influenced contemporary theories of democracy.
Review the articles “John Locke” and “Jean Jacques Rousseau” in this week’s Learning Resources. Think about how social contract theory is related to contemporary democratic theory.
Select at least one classical democratic theorist and consider his influence on contemporary democratic theory.
With these thoughts in mind:
Post by Day 3
an analysis of the influence of at least one classical democratic theorist on modern democratic theory. Be specific and provide examples.
.
Discussion 11-Mitosis and meiosis are important processes. a) What.docx
Discussion 11
-Mitosis and meiosis are important processes. a) What does each accomplish; b) where in the human body can each occur and c) how do the cells produced compare in chromosome number to the parent cells?
Discussion 12
- Assumed simple dominant and recessive genetics apply for this discussion. You are looking at two people, one shows a dominant phenotype (in this example a tall person) and the other a recessive phenotype (in this example a short person). Is it possible to positively determine the genotype of either person? If so which one and why. Explain your answer.
.
Discussion 1 Coding Scholar of Change of Video # 3 (John Anner) .docx
Discussion 1: Coding Scholar of Change of Video # 3 (John Anner)
Brief Description of the Video
The scholar of change video (program transcript) was presented by John Anner, a PhD candidate in Public Policy Administration (with concentration on International Non-governmental Organizations. – Walden University.
Over the years, Anner have been
focusing on agricultural problems in Africa and the Caribbean, and later joined the Peace Corps, where he worked as a Peace Corps volunteer in agriculture in Mauritania and West Africa.
Anner has been a
practitioner for almost 30 years and quest to acquire a PhD is to enable him add some intellectual and academic rigor to his work.
He hope to
bring to bear, his knowledge, experience and understanding to build national policy networks targeted at addressing directed social problems.
Coding the Scholar Change
A code in qualitative inquiry is most often a word or a short phrase that symbolically assigns a summative, a summary, a salient or essence-capturing attribute, for some portion of language, or visual data (
Saldana, 2016)
. My coding preference will be the use of the Excel spreadsheet with the labelling of the columns to include; the video code number (under this, I’ll have my notes), the name of the student, gender, program of study, subject matter/topic, what happened in the video (under this I’ll have my transcript which will capture my report content), quick memo.
To demonstrate the first coding, for instance, I’ll have the following; under the column for video code number (I’ll have video #3), the column for the name of the student (I’ll have
John Anner
), under gender column (
male
), program of study (
PhD in Public Policy Administration
), subject matter/topic (
scholar of change
), under the transcript (I’ll have
focused his attention on agricultural problems in Africa and the Caribbean, and later joined the Peace Corps, and worked as a Peace Corps volunteer in agriculture in Mauritania, West Africa;
a practitioner for almost 30 years; his quest to acquire a PhD is to enable him add some intellectual and academic rigor to his work).
Explaining My Choice of Coding
Another attractive aspect of this qualitative coding system is the insertion of a column for
memos
. “Memos are a very important part of qualitative data analysis process because they offer a great platform to put very short notes which can be expanded and placed in in the researcher’s analytic memo notebook” (
Laureate Education - Producer, 2016). Again at periods of data analysis and reflections, a memo will enable the interviewer to
know what part of the text (or the questionnaire) the information came from and what the interviewer was thinking about at that period in time.
References
Anner, J. (2015).
John Anner, PhD student in public policy and administration
[Video file].
Laureate Education (Producer). (2016).
Introduction to coding
[Video file]. Baltimore, MD: Author.
Laureate Education (Producer). (2016).
Discussion 1 Managing Diverse TeamsFor the last half-century, the.docx
Discussion 1: Managing Diverse Teams
For the last half-century, the workforce in the United States has been undergoing tremendous demographic changes. For example, in 2009 women accounted for almost 48% of American workforce, compared to 37% in 1970 (Barsh & Yee, 2011). Additionally, workers under the age of 44, and those most likely to be in school, college, or professional training, are more ethnically and racially diverse than ever before (Policy Alert, 2005). This is only diversity of gender, race, and ethnicity; consider how managers today must also lead increasingly diverse teams in terms of age, experience, nationality, geographic location, and even diversity of thinking styles. Contemporary businesses draw employees from a more diverse pool of talent than ever before. To be successful, top managers must understand how to develop and lead diverse teams.
Managing a group composed of individuals with unique cultures, backgrounds, personalities, and abilities can be a daunting task. As a manager, it is your responsibility to ensure that team and group interactions are successful. As you review the Learning Resources this week to prepare for your Discussion posting, think about how you define diversity and diversity affects teams. Pay particular attention to the media resource, “Will Differences Doom the Team,” which presents some of the challenges managers face when leading a diverse team, and consider the key competencies managers must possess to effectively manage a diverse team. As you prepare for your post, consider what diversity means for you and how the diversity you have encountered in your professional experience have impacted how the team functions.
.
Discussion 1 ClassismIncome and wages are measurable indicators.docx
Discussion 1: Classism
Income and wages are measurable indicators of how prosperity is distributed amongst social class. Wealth, often determined by an individual's net worth (assets minus liabilities), is another indicator that is used to determine class. Wealth for working class families is measured by their cars, savings, and home. As people improve their social and economic standing, wealth may include things like stocks and bonds, commercial real estate, and expensive jewelry.
Wealth is an important indicator because it spans past, present, and future generations. For example, compare the children of parents who can save money and leave an inheritance with children of parents who economically struggle and have few assets to pass on to the next generation. Historically, the creation and accumulation of wealth provides evidence of the legacy of racism, sexism, and discrimination and their role in determining class. Black/African Americans, women, and Hispanic/Latinos have historically been denied the means to obtain assets and grow wealth. Consider the impact of chronic marginalization on the Black/African American community's ability to build wealth. While the income gaps between various ethnic groups may be decreasing, the gap between assets remains wide. Data from the Pew Research center show that the median wealth of Caucasian households is 20 times that of Black/African American households and 18 times that of Hispanic/Latinos households in the U.S. (Pew Research Center, 2011).
Class extends beyond wealth and other financial indicators. Class also includes details like the amount of free time you enjoy (because you are not working three jobs to make ends meet) or feeling like there is a "right" way to speak and act in order to be heard. For this Discussion, analyze how classism has impacted your life.
·
Post
an analysis of how classism has factored into your life.
·
Then, explain a strategy you might use as a social worker to address the impact of class and class differences on the lives of your clients.
References (use 2 or more)
Adams, M., Blumenfeld, W. J., Castaneda, C., Hackman, H. W., Peters, M. L., & Zuniga, X. (Eds.). (2013).
Readings for diversity and social justice
. (3rd ed.). New York, NY: Routledge Press.
Discussion 2: Power, Privilege, and Classism
Power, privilege, and classism are interconnected. The more privilege you enjoy, the more power you have to access opportunities that build wealth. The more wealth you can amass, the higher your social standing. It is important to note that having wealth is not an indictment. However, the privileges that have often led to inequalities in wealth distribution are real. As a social worker, you may find yourself working with clients who do not enjoy the privileges you knowingly or unknowingly enjoy. The more you understand your own relationship to power, privilege, and class, the better you will understand your clients' realities. For this Discussion, review how classis.
Discussion 1 Cultural IdentityWhat is culture Is it synonymous w.docx
Discussion 1: Cultural Identity
What is culture? Is it synonymous with nationality? Can culture emerge from the intersection of multiple factors, such as gender identity, ability status, or language? Consider these questions as you prepare to describe your own culture.
For this Discussion, think about how you would identify your culture. Consider aspects of your identity.
I am black, a male, christian, heterosexual and do not have any disabilites.
Or explain any other identifiers that contribute to what you would consider your culture.
Post a description of important aspects of your culture that an outsider might not know.
Explain the information a social worker would need to know about your culture in order to effectively assist your family in the face of a pressing issue.
Describe potential consequences of a lack of cultural awareness on the social worker’s part.
References
James, J., Green, D., Rodriguez, C., & Fong, R. (2008). Addressing disproportionality through undoing racism, leadership development, and community engagement.
Child Welfare, 87
(2), 279–296.
[removed]O’Brien, M. (2011). Equality and fairness: Linking social justice and social work practice.
Journal of Social Work, 11
(2), 143–158.
.
Discuss the value of studying the arts. Consider the following quest.docx
Discuss the value of studying the arts. Consider the following questions:
What can it teach us about the past? The present? The future?
How has art influenced society? How has society influenced art?
How does an awareness of all of this impact your own life?
a 2page paragraph.
.
Discussion $5.00 Please use detailDiscuss the importance of pos.docx
Discussion $5.00 Please use detail
Discuss the importance of positive socialization and how different cultural and ethical perspectives influence different aspects of development, self-concept, and identity.
Evaluate environmental influences such as geographical variance, religious beliefs, and the construction of the school setting (e.g., boarding school versus public school, traditional versus experiential learning) for cultural and ethical differences on development.
Short Paper $10.00 at least 3 pages and 3 cited sources apa format. Please answer all questions
Prompt:
Based on the articles you read in Module Four on gender dysphoria, write a short paper about the influence of acceptance, parenting styles, and how
these can directly steer a child’s gender id
entity. Moreover, think about society today and acceptance of varied gender roles compared to the 1950s.
Also, consider and explore society’s influence on gender dysphoria in your argument. Is there a direct correlation to gender
identity and society or not?
Gender Dysphoria: Two Steps Forward, One Step Back
Gender Dysphoria
Gender Stereotypes in the Family Context: Mothers, Fathers, and Siblings
The Early Development of Gender Differences
Specifically, your paper should address the following:
What is different today in
parenting styles
compared to the 1950s?
Considering the criteria and changes made in the DSM in the most recent version (DSM-5) compared to earlier, outdated versions, is there a direct
correlation to
gender identity and society
or not?
.
Discuss why terrorism is difficult to quantify and has numerous defi.docx
Discuss why terrorism is difficult to quantify and has numerous definitions that are used throughout the world. In addition, compare and contrast the definitions of terrorism from the following agencies: FBI, DOD, DHS, DIA, CIA, U.S. State Department. What similarities or differences do you notice? Are the definitions aligned with the individual agency mission? Do you think the “cyclical nature of violence” discussed by Combs bears on these differences? Why or why not?
at least one page please answer all questions
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