APA format in a SOAP Note format. 1 page long with questions as to dirkrplav
APA format in a SOAP Note format. 1 page long with questions as to which diagnosis would be accurate and why. I have included the references I need 3 peer review articles to be included
Patient Information:
Initials
: JS
Age
: 11
Sex
: M
Race
: Caucasian
SJ
CC:
Patient complaining of a mild right earache for the last two days and trouble hearing from that ear.
HPI
: James Jones is an 11 year old Caucasian male who presents to the clinic with complaints of a right earache for the last two days. The patient reports worsening pain at night when trying to fall asleep and difficulty hearing out of that ear. The patient rates is earache pain 5/10 and describes it as sharp and constant. The patient has taken 600mg ibuprofen with minimal relief of pain. The patient reports that he has been spending a lot of time swimming in the pool this summer.
Current Medications
:
1. Ibuprofen 600mg PRN for earache pain
Allergies:
NKA
PMHx
: Up to date on all immunizations. No significant PMH.
Soc Hx
: Patient lives with two siblings and supportive parents in a safe neighborhood in Boston. The patient is currently in middle school and enjoys playing soccer, fishing with his dad and swimming in his pool during the summer.
Fam Hx
: Maternal grandmother died of a stroke at the age of 70. No other significant family history.
ROS
:
GENERAL: No fever, fatigue or chills. No weight loss.
HEENT:
Eyes:
No visual loss, blurred vision, double vision or yellow sclerae.
Ears:
Patient reporting pain in right ear and hearing loss.
Nose,
Throat:
No sneezing, congestion, runny nose or sore throat.
SKIN: No rashes or itching.
RESPIRATORY: No shortness of breath, cough or sputum.
GASTROINTESTINAL: No anorexia, nausea, vomiting or diarrhea. No abdominal pain or blood.
NEUROLOGICAL: No headache, dizziness, syncope, paralysis, ataxia, numbness or tingling in the extremities. No change in bowel or bladder control.
LYMPHATICS: No enlarged nodes. No history of splenectomy.
ALLERGIES: No history of asthma, hives, eczema or rhinitis.
O.
GENERAL: Patient comes to the clinic with his grandmother, patient appears uncomfortable, is rubbing his right ear and having difficulty hearing.
HEENT: PEERLA.
Ears:
Right ear canal is erythematous and edematous with pus present, tympanic membrane is difficult to visualize. Hearing difficulty with right ear. Left ear canal is intact without erythema or edema, tympanic membrane is clear and intact.
Nose
: Nose is patent without any rhinorrhea.
Throat:
Oropharynx is clear, without erythema or exudates, mucous membranes are moist, pink and intact. (Sullivan, 2012).
SKIN: Skin color is normal for patient, intact, without rashes or lesions. Skin turgor is good.
RESPIRATORY: LS CTA bilaterally, no sternal retractions noted.
GASTROINTESTINAL: Abdomen is soft, nontender, nondistended. + BS in all quadrants. No bruits noted. No splenomegaly or masses present.
NEUROLOGICAL: Cranial ...
Tympanic Membraneby Lisa MikeFILET IME SUBMIT T ED 1.docxmarilucorr
Tympanic Membrane
by Lisa Mike
FILE
T IME SUBMIT T ED 17 - DEC- 2016 12:02PM
SUBMISSION ID 7 54 4 537 7 9
WORD COUNT 14 00
CHARACT ER COUNT 7 57 8
ORDER_4 4 897 _109194 .DOC (39.5K)
%35
SIMILARIT Y INDEX
%7
INT ERNET SOURCES
%4
PUBLICAT IONS
%34
ST UDENT PAPERS
1 %30
2 %2
3 %1
4 %1
5 %1
EXCLUDE QUOT ES OFF
EXCLUDE
BIBLIOGRAPHY
OFF
EXCLUDE MAT CHES OFF
Tympanic Membrane
ORIGINALITY REPORT
PRIMARY SOURCES
Submitted to EDMC
St udent Paper
Submitted to AUT University
St udent Paper
journals.lww.com
Int ernet Source
etheses.bham.ac.uk
Int ernet Source
ukplatinumessays.com
Int ernet Source
Tympanic Membraneby Lisa MikeTympanic MembraneORIGINALITY REPORTPRIMARY SOURCES
1
Running head: WEEK TWO ASSIGNMENT TWO
8
WEEK TWO ASSIGNMENT TWO
Week Two Assignment Two: Tympanic Membrane and Thyroid Gland
Sample Student Paper
South University
NSG 3012
Week Two Assignment Two: Tympanic Membrane and Thyroid Gland
Conducting a thorough examination of the tympanic membrane and thyroid gland can identify the cause of presenting symptoms. When a patient reports ear pain, blockage, loss of hearing, and/or ear ringing the nurse will need to perform a thorough assessment to identify the cause. Tympanic ear perforation is one issue that may be identified. Additionally, when a patient reports recent weight loss, weight gain, hair loss, fatigue, irritability, and sensitivity to heat or cold, the nurse may suspect thyroid problems and will examine the thyroid. Dysfunction of the thyroid can lead to many problems, hypothyroidism is one such issue, caused by the thyroid not producing the thyroid hormone (Jarvis, 2016). An overview of the tympanic membrane and thyroid gland will be discussed to further detail the associated assessments.
Health History One
A 19-year-old Hispanic male presents to the primary care office with a constant earache lasting three days. He describes the dulling pain as deep in his left ear. He rates the pain as a 10 out of 10. He has a temperature of 101.1. It is suspected the patient may have an ear infection. The patient reports a history of ear infections. Patient denies hearing loss, discharge, ringing or buzzing, and/or ear injury.
Findings for Tympanic Membrane
Examination of the ear are mainly performed using inspection and palpation (Jarvis, 2016). The client was seated on the exam table, with the examiner’s head at the same level as the client’s. The examiner begins by inspecting both auricles for abnormalities. No abnormalities were noted, but the left ear is red in color. The auricles and mastoid areas were palpated to check for swelling, tenderness, or nodules. The left ear was tender to touch. When using an otoscope, the provider is examining the external auditory canal and tympanic membrane. When inspecting the pinna, it is important to look for lesions (Kalyanakrishnan, Sparks, & Berryhill, 2007). Inspecting the canal, the examiner is looking f ...
APA format in a SOAP Note format. 1 page long with questions as to dirkrplav
APA format in a SOAP Note format. 1 page long with questions as to which diagnosis would be accurate and why. I have included the references I need 3 peer review articles to be included
Patient Information:
Initials
: JS
Age
: 11
Sex
: M
Race
: Caucasian
SJ
CC:
Patient complaining of a mild right earache for the last two days and trouble hearing from that ear.
HPI
: James Jones is an 11 year old Caucasian male who presents to the clinic with complaints of a right earache for the last two days. The patient reports worsening pain at night when trying to fall asleep and difficulty hearing out of that ear. The patient rates is earache pain 5/10 and describes it as sharp and constant. The patient has taken 600mg ibuprofen with minimal relief of pain. The patient reports that he has been spending a lot of time swimming in the pool this summer.
Current Medications
:
1. Ibuprofen 600mg PRN for earache pain
Allergies:
NKA
PMHx
: Up to date on all immunizations. No significant PMH.
Soc Hx
: Patient lives with two siblings and supportive parents in a safe neighborhood in Boston. The patient is currently in middle school and enjoys playing soccer, fishing with his dad and swimming in his pool during the summer.
Fam Hx
: Maternal grandmother died of a stroke at the age of 70. No other significant family history.
ROS
:
GENERAL: No fever, fatigue or chills. No weight loss.
HEENT:
Eyes:
No visual loss, blurred vision, double vision or yellow sclerae.
Ears:
Patient reporting pain in right ear and hearing loss.
Nose,
Throat:
No sneezing, congestion, runny nose or sore throat.
SKIN: No rashes or itching.
RESPIRATORY: No shortness of breath, cough or sputum.
GASTROINTESTINAL: No anorexia, nausea, vomiting or diarrhea. No abdominal pain or blood.
NEUROLOGICAL: No headache, dizziness, syncope, paralysis, ataxia, numbness or tingling in the extremities. No change in bowel or bladder control.
LYMPHATICS: No enlarged nodes. No history of splenectomy.
ALLERGIES: No history of asthma, hives, eczema or rhinitis.
O.
GENERAL: Patient comes to the clinic with his grandmother, patient appears uncomfortable, is rubbing his right ear and having difficulty hearing.
HEENT: PEERLA.
Ears:
Right ear canal is erythematous and edematous with pus present, tympanic membrane is difficult to visualize. Hearing difficulty with right ear. Left ear canal is intact without erythema or edema, tympanic membrane is clear and intact.
Nose
: Nose is patent without any rhinorrhea.
Throat:
Oropharynx is clear, without erythema or exudates, mucous membranes are moist, pink and intact. (Sullivan, 2012).
SKIN: Skin color is normal for patient, intact, without rashes or lesions. Skin turgor is good.
RESPIRATORY: LS CTA bilaterally, no sternal retractions noted.
GASTROINTESTINAL: Abdomen is soft, nontender, nondistended. + BS in all quadrants. No bruits noted. No splenomegaly or masses present.
NEUROLOGICAL: Cranial ...
Tympanic Membraneby Lisa MikeFILET IME SUBMIT T ED 1.docxmarilucorr
Tympanic Membrane
by Lisa Mike
FILE
T IME SUBMIT T ED 17 - DEC- 2016 12:02PM
SUBMISSION ID 7 54 4 537 7 9
WORD COUNT 14 00
CHARACT ER COUNT 7 57 8
ORDER_4 4 897 _109194 .DOC (39.5K)
%35
SIMILARIT Y INDEX
%7
INT ERNET SOURCES
%4
PUBLICAT IONS
%34
ST UDENT PAPERS
1 %30
2 %2
3 %1
4 %1
5 %1
EXCLUDE QUOT ES OFF
EXCLUDE
BIBLIOGRAPHY
OFF
EXCLUDE MAT CHES OFF
Tympanic Membrane
ORIGINALITY REPORT
PRIMARY SOURCES
Submitted to EDMC
St udent Paper
Submitted to AUT University
St udent Paper
journals.lww.com
Int ernet Source
etheses.bham.ac.uk
Int ernet Source
ukplatinumessays.com
Int ernet Source
Tympanic Membraneby Lisa MikeTympanic MembraneORIGINALITY REPORTPRIMARY SOURCES
1
Running head: WEEK TWO ASSIGNMENT TWO
8
WEEK TWO ASSIGNMENT TWO
Week Two Assignment Two: Tympanic Membrane and Thyroid Gland
Sample Student Paper
South University
NSG 3012
Week Two Assignment Two: Tympanic Membrane and Thyroid Gland
Conducting a thorough examination of the tympanic membrane and thyroid gland can identify the cause of presenting symptoms. When a patient reports ear pain, blockage, loss of hearing, and/or ear ringing the nurse will need to perform a thorough assessment to identify the cause. Tympanic ear perforation is one issue that may be identified. Additionally, when a patient reports recent weight loss, weight gain, hair loss, fatigue, irritability, and sensitivity to heat or cold, the nurse may suspect thyroid problems and will examine the thyroid. Dysfunction of the thyroid can lead to many problems, hypothyroidism is one such issue, caused by the thyroid not producing the thyroid hormone (Jarvis, 2016). An overview of the tympanic membrane and thyroid gland will be discussed to further detail the associated assessments.
Health History One
A 19-year-old Hispanic male presents to the primary care office with a constant earache lasting three days. He describes the dulling pain as deep in his left ear. He rates the pain as a 10 out of 10. He has a temperature of 101.1. It is suspected the patient may have an ear infection. The patient reports a history of ear infections. Patient denies hearing loss, discharge, ringing or buzzing, and/or ear injury.
Findings for Tympanic Membrane
Examination of the ear are mainly performed using inspection and palpation (Jarvis, 2016). The client was seated on the exam table, with the examiner’s head at the same level as the client’s. The examiner begins by inspecting both auricles for abnormalities. No abnormalities were noted, but the left ear is red in color. The auricles and mastoid areas were palpated to check for swelling, tenderness, or nodules. The left ear was tender to touch. When using an otoscope, the provider is examining the external auditory canal and tympanic membrane. When inspecting the pinna, it is important to look for lesions (Kalyanakrishnan, Sparks, & Berryhill, 2007). Inspecting the canal, the examiner is looking f ...
Instructions· This week’s case study will introduce concepts r.docxmariuse18nolet
Instructions
· This week’s case study will introduce concepts related to the pulmonary system and shock states. Read the scenario and thoroughly complete the questions. Some of the answers will be short answers and may not require a lot of details. For example: what is the most common organism to cause a hospital acquired infection? The answer is pseudomonas aeruginosa. Answers to questions that relate to the pathogenesis of a disease must include specific details on the process. For example: How does hypoxia lead to cellular injury? Simply writing that a lack of blood flow, causes a lack of oxygen available to the cell and the cell cannot function without oxygen is not sufficient. This type of response is NOT reflective of an advanced understanding of the concept or graduate level work. This answer should discuss the cascade of events leading to the lack of oxygen and how it specifically impairs cellular function. All answers to these type of questions should address the effects at the cellular level, then the effects on the organ and then the body as a whole. Additionally describing the normal anatomical and/or physiologic processes underlying the pathogenesis will be necessary to thoroughly answer the question.
It is very likely that you will need to reference multiple sources to answer the questions thoroughly. Your text book will not necessarily have all the answers. Only professional sources may be used to complete the assignment. These include text books, primary and secondary journal articles from peer reviewed journals, government and university websites, and publications from professional societies who establish disease management guidelines and recommendations. Sources such as Wikipedia or other generic websites are not considered professional references and should not be used to complete the case studies.
· Reason for Consultation:
Desaturation to 64% on room air 1 hour ago with associated shortness of breath.
History of Present Illness:
Mrs. X is 73-year-old Caucasian female who was admitted to the general surgery service 3 days ago for a leaking j-tube which was surgically replaced 2 days ago. This morning at 07:30, the RN reported that the patient was sleeping and doing fine, then the CNA made rounds at 0900 and Mrs. X was found to be mildly dyspneic. Vital signs were checked at that time and were; temperature 38.6, pulse 120, respirations 20, blood pressure 138/38. O2 sat was 64% on room air. The general surgeon was notified by the nursing staff of the hypoxia, an order for a chest x-ray and oxygen therapy were given to the RN. The O2 sat is maintaining at 91-92% on 4L NC. The patient was seen and examined at 10:10 a.m. She reported that she has had mild dyspnea for 2 days that has progressively gotten worse. She does not use oxygen at home. Her respiratory rate at the time of this visit was 20 and she feels short of breath. She has felt this way in the past when she had pneumonia. She is currently undergoing radiatio.
2. Caritas Holy Family Hospital and Medical Center HFOO639699
MEDICAL RECORDS REPORT CONSULTATION REPORT
DATE CF SURGERY: September 3, 2003, at Huly Family Hospital.
Ob‘ MLNEJSS: This is a EL year old female with history of zwsal ubstructiwn facial
yrussurc, She has had nu improvement with medication. In addition, she has some ear
blocl-age popping uh the right side.
FAST MEDICAL HISTORY: None.
MEIDICATIONS: and Flonase.
ALLERGIES: Penicillin and Sulfa, as well as Aspirin. TOBACCO £1 ALCOHOL: NONE.
BLEEDING HISTORY; Hum.-;.
ASSESSMENT:
L. Eustachian tube dysfunction with hearing on right side. 2. aeptal dEViotiur‘..
3. ‘fuzbinate hypertrophy.
4 . Chronic sinusiti= .
ELAN: Right myringutumy and tub»: with Septuplasty, turbinectumy limited endoscopic
sinus surgery. The risks, benefits and alternatives were discussed with the patient
preoperatively, and all questiuns were answered and informed consent was obtained. She
wishes to proceed with the proce-d".1res. In