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Name: Pt. Encounter Number: Date: Age: Sex: SUBJECTIVE CC: Reason given by the patient for seeking medical care “in quotes” HPI: Describe the course of the patient’s illness, including when it began, character of symptoms, location where the symptoms began, aggravating or alleviating factors, pertinent positives and negatives, other related diseases, past illnesses, and surgeries or past diagnostic testing related to the present illness. Medications: (List with reason for med ) PMH Allergies: Medication Intolerances: Chronic Illnesses/Major traumas Hospitalizations/Surgeries “Have you ever been told that you have diabetes, HTN, peptic ulcer disease, asthma, lung disease, heart disease, cancer, TB, thyroid problems, kidney problems, or psychiatric diagnosis?” Family History Does your mother, father, or siblings have any medical or psychiatric illnesses? Is anyone diagnosed with: lung disease, heart disease, HTN, cancer, TB, DM, or kidney disease? Social History Education level, occupational history, current living situation/partner/marital status, substance use/abuse, ETOH, tobacco, and marijuana. Safety status ROS General Weight change, fatigue, fever, chills, night sweats, and energy level Cardiovascular Chest pain, palpitations, PND, orthopnea, and edema Skin Delayed healing, rashes, bruising, bleeding or skin discolorations, and any changes in lesions or moles Respiratory Cough, wheezing, hemoptysis, dyspnea, pneumonia hx, and TB Eyes Corrective lenses, blurring, and visual changes of any kind Gastrointestinal Abdominal pain, N/V/D, constipation, hepatitis, hemorrhoids, eating disorders, ulcers, and black, tarry stools Ears Ear pain, hearing loss, ringing in ears, and discharge Genitourinary/Gynecological Urgency, frequency burning, change in color of urine. Contraception, sexual activity, STDs Female: last pap, breast, mammo, menstrual complaints, vaginal discharge, pregnancy hx Male: prostate, PSA, urinary complaints Nose/Mouth/Throat Sinus problems, dysphagia, nose bleeds or discharge, dental disease, hoarseness, and throat pain Musculoskeletal Back pain, joint swelling, stiffness or pain, fracture hx, and osteoporosis Breast SBE, lumps, bumps, or changes Neurological Syncope, seizures, transient paralysis, weakness, paresthesias, and black-out spells Heme/Lymph/Endo HIV status, bruising, blood transfusion hx, night sweats, swollen glands, increase thirst, increase hunger, and cold or heat intolerance Psychiatric Depression, anxiety, sleeping difficulties, suicidal ideation/attempts, and previous dx OBJECTIVE Weight BMI Temp BP Height Pulse Resp General Appearance Healthy-appearing adult female in no acute distress. Alert and oriented; answers questions appropriately. Slightly somber affect at first and then brighter later. Skin Skin.
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Name Pt. Encounter Number Date Age Sex SUBJ
Name: Pt. Encounter Number:
Date: Age: Sex:
SUBJECTIVE
CC:
Reason given by the patient for seeking medical care “in quotes”
HPI:
Describe the course of the patient’s illness, including when it began, character of symptoms, location
where the symptoms began, aggravating or alleviating factors, pertinent positives and negatives, other
related diseases, past illnesses, and surgeries or past diagnostic testing related to the present illness.
Medications: (List with reason for med )
PMH
Allergies:
Medication Intolerances:
Chronic Illnesses/Major traumas
Hospitalizations/Surgeries
“Have you ever been told that you have diabetes, HTN, peptic ulcer disease, asthma, lung disease, heart
disease, cancer, TB, thyroid problems, kidney problems, or psychiatric diagnosis?”
Family History
Does your mother, father, or siblings have any medical or psychiatric illnesses? Is anyone diagnosed with:
lung disease, heart disease, HTN, cancer, TB, DM, or kidney disease?
Social History
Education level, occupational history, current living situation/partner/marital status, substance use/abuse,
ETOH, tobacco, and marijuana. Safety status
ROS
General
Weight change, fatigue, fever, chills, night sweats,
and energy level
Cardiovascular
Chest pain, palpitations, PND, orthopnea, and
edema
Skin
Delayed healing, rashes, bruising, bleeding or skin
discolorations, and any changes in lesions or moles
Respiratory
Cough, wheezing, hemoptysis, dyspnea, pneumonia
hx, and TB
Eyes
Corrective lenses, blurring, and visual changes of
any kind
Gastrointestinal
Abdominal pain, N/V/D, constipation, hepatitis,
hemorrhoids, eating disorders, ulcers, and black,
tarry stools
Ears
Ear pain, hearing loss, ringing in ears, and
discharge
Genitourinary/Gynecological
Urgency, frequency burning, change in color of
urine.
Contraception, sexual activity, STDs
Female: last pap, breast, mammo, menstrual
complaints, vaginal discharge, pregnancy hx
Male: prostate, PSA, urinary complaints
Nose/Mouth/Throat
Sinus problems, dysphagia, nose bleeds or
discharge, dental disease, hoarseness, and throat
pain
Musculoskeletal
Back pain, joint swelling, stiffness or pain, fracture
hx, and osteoporosis
Breast
SBE, lumps, bumps, or changes
Neurological
Syncope, seizures, transient paralysis, weakness,
paresthesias, and black-out spells
Heme/Lymph/Endo
HIV status, bruising, blood transfusion hx, night
sweats, swollen glands, increase thirst, increase
hunger, and cold or heat intolerance
Psychiatric
Depression, anxiety, sleeping difficulties, suicidal
ideation/attempts, and previous dx
OBJECTIVE
Weight BMI Temp BP
Height Pulse Resp
General Appearance
Healthy-appearing adult female in no acute distress. Alert and oriented; answers questions appropriately.
Slightly somber affect at first and then brighter later.
Skin
Skin ...
Breast Cancer SOAP noteName Sharon BroomDate Januar
Breast Cancer SOAP note
Name Sharon Broom
Date: January/17/2020.
Age: 45 years old
Gender: Female
Time:12:45
SUBJECTIVE:
Chief Complaint:
“I have a sore lump on the left breast."
History of Present Illness:
Sharon is a 45-year-old female with complaints of a painful lump on her left breast for a month. The patient indicates that she feels unbalanced lumps on her left breast that are painful on the outer and upper corners. The patient observed the areas of the left outer breast worsening in terms of size and pain in the past week. She has experienced the pain of level four out of ten. Her mother was detected to have breast cancer prior to the age of 50. She has had a history of hysterectomy because of irregular periods, menorrhagia. The patient refutes swelling, increased warmth, and redness of the left breast. She repudiates nipple discharge swollen glands, chills, and fever.
History
Past Medical History:
Fibrocystic breast disease, Vitamin D deficiency, Urinary tract infection, Hypothyroidism, Hypocalcemia, and Constipation
Screenings:
Blood Pressure screening (2016 N/A)
Dental Examination (2016 N/A)
Eye Examination (2016 N/A)
Mammogram (2016 BiRad 2)
Pap smear- normal
HPV test- normal
GTPAL: G=1.T=0. P=0. A=0. L=1 (Normal vaginal delivery without complication)
Menstrual Hx: started at the age of 14. Normal PAP outcomes. LMP (cannot recall)-hysterectomy (07.2012)
Post Hospitalizations: Admitted to hospital for hysterectomy for one week
Past Surgical History: Hysterectomy (07. 2012)
Medications:
Armour Thyroid 30mg oral tablet: consume two pills on Monday, Wednesday, and Friday and three pills other days.
Therapy: 15 May 2015
Last Rx: 5 April 2016
Allergies:
Food allergies, Penicillin Triple Sulfa Vaginal CREA
Family History:
The patient’s mother passed away at the age of fifty, with a medical history of breast cancer. Sharon’s father is still alive at the age of seventy, with a medical record of hypertension. The patient has a younger brother aged 35 years and has no medical glitches. The patient has a sixteen-year-old son, who is healthy.
Social History:
The patient is divorced, and she lives with her son. She does not smoke but consumes alcohol irregularly. Sharon takes a regular diet that has no restrictions. She has no worries about weight loss or gains since she exercises two to three times weekly. The patient continually puts on a seatbelt when driving, wears sunscreen.
Sexual/Contraceptive History:
She has not been sexually active for at least a year, but previously, she had a monogamous relation. Birth control: Utilized condoms before. The patient has no fears with sexual performance or feelings.
...
Analyze the subjective portion of the note. List additional inform.docx
Analyze the subjective portion of the note. List additional information that should be included in the documentation.
Analyze the objective portion of the note. List additional information that should be included in the documentation.
Is the assessment supported by the subjective and objective information? Why or why not?
Would diagnostics be appropriate for this case, and how would the results be used to make a diagnosis?
Would you reject/accept the current diagnosis? Why or why not? Identify three possible conditions that may be considered as a differential diagnosis for this patient. Explain your reasoning using at least three different references from current evidence-based literature.
GENITALIA ASSESSMENT
Subjective:
CC: “I have bumps on my bottom that I want to have checked out.”
HPI: AB, a 21-year-old WF college student reports to your clinic with external bumps on her genital area. She states the bumps are painless and feel rough. She states she is sexually active and has had more than one partner during the past year. Her initial sexual contact occurred at age 18. She reports no abnormal vaginal discharge. She is unsure how long the bumps have been there but noticed them about a week ago. Her last Pap smear exam was 3 years ago, and no dysplasia was found; the exam results were normal. She reports one sexually transmitted infection (chlamydia) about 2 years ago. She completed the treatment for chlamydia as prescribed.
PMH: Asthma
Medications: Symbicort 160/4.5mcg
Allergies: NKDA
FH: No hx of breast or cervical cancer, Father hx HTN, Mother hx HTN, GERD
Social: Denies tobacco use; occasional etoh, married, 3 children (1 girl, 2 boys)
Objective:
VS: Temp 98.6; BP 120/86; RR 16; P 92; HT 5’10”; WT 169lbs
Heart: RRR, no murmurs
Lungs: CTA, chest wall symmetrical
Genital: Normal female hair pattern distribution; no masses or swelling. Urethral meatus intact without erythema or discharge. Perineum intact. Vaginal mucosa pink and moist with rugae present, pos for firm, round, small, painless ulcer noted on external labia.
Abd: soft, normoactive bowel sounds, neg rebound, neg murphy’s, negMcBurney
Diagnostics: HSV specimen obtained
Assessment:
Chancre
Episodic/Focused SOAP Note Template
Patient Information:
Initials, Age, Sex, Race
S.
CC
(chief complaint) a BRIEF statement identifying why the patient is here - in the patient’s own words - for instance "headache", NOT "bad headache for 3 days”.
HPI
: This is the symptom analysis section of your note. Thorough documentation in this section is essential for patient care, coding, and billing analysis. Paint a picture of what is wrong with the patient. Use LOCATES Mnemonic to complete your HPI. You need to start EVERY HPI with age, race, and gender (e.g., 34-year-old AA male). You must include the seven attributes of each principal symptom in paragraph form not a list. If the CC was “headache”, the LOCATES for the HPI might look like the following example:
L.
Name Pt. Encounter Number Date Age Sex SUBJ.docx
Name: Pt. Encounter Number:
Date: Age: Sex:
SUBJECTIVE
CC:
Reason given by the patient for seeking medical care “in quotes”
HPI:
Describe the course of the patient’s illness, including when it began, character of symptoms, location
where the symptoms began, aggravating or alleviating factors, pertinent positives and negatives, other
related diseases, past illnesses, and surgeries or past diagnostic testing related to the present illness.
Medications: (List with reason for med )
PMH
Allergies:
Medication Intolerances:
Chronic Illnesses/Major traumas
Hospitalizations/Surgeries
“Have you ever been told that you have diabetes, HTN, peptic ulcer disease, asthma, lung disease, heart
disease, cancer, TB, thyroid problems, kidney problems, or psychiatric diagnosis?”
Family History
Does your mother, father, or siblings have any medical or psychiatric illnesses? Is anyone diagnosed with:
lung disease, heart disease, HTN, cancer, TB, DM, or kidney disease?
Social History
Education level, occupational history, current living situation/partner/marital status, substance use/abuse,
ETOH, tobacco, and marijuana. Safety status
ROS
General
Weight change, fatigue, fever, chills, night sweats,
and energy level
Cardiovascular
Chest pain, palpitations, PND, orthopnea, and
edema
Skin
Delayed healing, rashes, bruising, bleeding or skin
discolorations, and any changes in lesions or moles
Respiratory
Cough, wheezing, hemoptysis, dyspnea, pneumonia
hx, and TB
Eyes
Corrective lenses, blurring, and visual changes of
any kind
Gastrointestinal
Abdominal pain, N/V/D, constipation, hepatitis,
hemorrhoids, eating disorders, ulcers, and black,
tarry stools
Ears
Ear pain, hearing loss, ringing in ears, and
discharge
Genitourinary/Gynecological
Urgency, frequency burning, change in color of
urine.
Contraception, sexual activity, STDs
Female: last pap, breast, mammo, menstrual
complaints, vaginal discharge, pregnancy hx
Male: prostate, PSA, urinary complaints
Nose/Mouth/Throat
Sinus problems, dysphagia, nose bleeds or
discharge, dental disease, hoarseness, and throat
pain
Musculoskeletal
Back pain, joint swelling, stiffness or pain, fracture
hx, and osteoporosis
Breast
SBE, lumps, bumps, or changes
Neurological
Syncope, seizures, transient paralysis, weakness,
paresthesias, and black-out spells
Heme/Lymph/Endo
HIV status, bruising, blood transfusion hx, night
sweats, swollen glands, increase thirst, increase
hunger, and cold or heat intolerance
Psychiatric
Depression, anxiety, sleeping difficulties, suicidal
ideation/attempts, and previous dx
OBJECTIVE
Weight BMI Temp BP
Height Pulse Resp
General Appearance
Healthy-appearing adult female in no acute distress. Alert and oriented; answers questions appropriately.
Slightly somber affect at first and then brighter later.
Skin
Skin.
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 ...
Contraception Essays.docx
This document discusses contraceptive options for a 38-year-old woman. It provides her medical history including asthma, migraines, IBS, and family history of various medical conditions. It notes her physical exam findings and asks additional questions needed to determine the best contraceptive method for her given her medical history and symptoms.
Running head SKIN CONDITIONS AND DIFFERENTIAL DIAGNOSIS 1SKIN.docx
Running head: SKIN CONDITIONS AND DIFFERENTIAL DIAGNOSIS 1
SKIN CONDITIONS AND DIFFERENTIAL DIAGNOSIS 7
Skin Conditions and Differential Diagnosis
Adesola Turner
Walden University
NURS-6512N-17
Advanced Health Assessment.
December 22, 2019.
Introduction
The number 2 graphic (figure below) is characterized as Cherry angiomas that appear in older adults. With time cherry angiomas turn dark, though after infection it is identified by round tiny bright ruby red papules. As age numerically increase Dunphy et al (2015) argues that the disease virtually occurs to everyone above the age of 30 years. One of the ways in which I would perform differential diagnosis is by observing the skin of a patient who is 70 years of age.
Graphic #2
Patient Initials: AB Age: 70 Gender: male
SUBJECTIVE DATA:
Chief Complaint (CC): AB comes in clinic complaining about development of hard red bumps on the chest
History of Present Illness (HPI): Patient AB who is 70 years old comes in the hospital with complaints of having red bumps on his chest that appeared 2 weeks ago. He states that he wants to be done aa physical examination to be performed. AB says that last year he developed at least 4 new bumps on his chest that formed gradually. He is filled with anxiety because upon doing a Google search about his condition, he found that it could some tumors that are developing on his chest. He deniesrefutes any bleeding, painful and itchy bumps, exudation, or any climate variations. The bumps are located around the chest and the abdomen. AB says he has not come into contact with an irritant, denies having a fever, or does he take medications. Also, he reports he is neither under stress nor lifestyle changes. He claims, no one in his family lineage has ever been diagnosed with skin cancer.
Medications: none
Allergies: NKDA
Past Medical History (PMH): identified with stage 4 blood pressure Hypertension and the age of 60 which was well managed.
Past Surgical History (PSH): At age 40, his left shoulder was repaired from a torn rotator cuff.
Sexual/Reproductive History: Married and not sexually active.
Personal/Social History: denies smoking, taking alcohol, substance abuse, or under any influence of ETOH
Immunization History: His immunizations are current. In 2017, he got immunized of Pneumococcal vaccines and influenza vaccine
Significant Family History: Living with no parents who perished from a car accident. Living with his healthy daughter whom he got at his 30s
Social History: Live with her daughter and his 3 grandchildren. Being a widow for 8 years, he has been working as an engineer before he retired. In his free time, he does light exercises. Every day he attends catholic mass and then joins his 6 friends for breakfast at the local diner.
Review of Systems (ROS):
General: Mr. AB is a well-organized and neat man. He is alert and corporate during the discussion. He responds t ...
Bacterial Vaginosis Zahavah is a 16 years Gender Female Race .docx
Bacterial Vaginosis
Zahavah is a 16 years Gender: Female Race: non-Hispanic White Diagnosis: bacterial vaginosis Subjective Data: HJ is a 16-year-old Hispanic female patient who presented to the office with her mother with a two week history of severe irritation and soreness of her vulva. The patient reported of having a two-week history of burning sensation on passing urine without increased urinary frequency. In addition, the patient complained of having a thick, creamy-white vaginal discharge. She had normal and regular menstrual periods. She agreed to having multiple sexual partners for the last one year since breaking up with her high school boyfriend. She denied taking medications in the management of the issue of concern. Objective Data: Vital signs; BP 110/76, HR 78, RR 26, temperature 98, and an oxygen saturation of 99 percent on room air. In general, HJ was a healthy lad who was well oriented to place, time, and person, without obvious distress. HEENT without issues of concern. On respiratory assessment, the patient had a clear and normal lung sounds bilaterally without crackles and wheezes. Cardiovascular assessment showing normal heart sound without murmurs and gallops. Normal bowel sounds on all quadrants on gastrointestinal examination. Patient denied to have a physical examination on the perineal area. Assessment: History of presenting illness indicating a possible bacterial vaginosis. Positive Whiff test indicating bacterial vaginosis. Plan of care: Clindamycin 300 mg orally twice daily for 7 days was prescribed to help in the management of the issues. Patient educated on the need to avoid multiple sexual partners to avoid reoccurrence of the issue as well as possible sexually transmitted diseases.
Answer below QUESTION
· Subjective: What details did the patient or parent provide regarding the personal and medical history? Include any discrepancies between the details provided by the child and details provided by the parent as well as possible reasons for these discrepancies.
· Objective: What observations did you make during the physical assessment? Include pertinent positive and negative physical exam findings. Describe whether the patient presented with any growth and development or psychosocial issues.
· Assessment: What were your differential diagnoses? Provide a minimum of three possible diagnoses. List them from highest priority to lowest priority and include their ICD-10 code for the diagnosis. What was your primary diagnosis and why?
· Plan: What was your plan for diagnostics and primary diagnosis? What was your plan for treatment and management? Include pharmacologic and non-pharmacologic treatments, alternative therapies, and follow-up parameters as well as a rationale for this treatment and management plan.
· Reflection notes: What was your “aha” moment? What would you do differently in a similar patient evaluation?
Note: Your Focused Note Assignment must be signed by Day 7 of Week 3.
PRAC 6541:
.
Recommended
Name Pt. Encounter Number Date Age Sex SUBJ
Name: Pt. Encounter Number:
Date: Age: Sex:
SUBJECTIVE
CC:
Reason given by the patient for seeking medical care “in quotes”
HPI:
Describe the course of the patient’s illness, including when it began, character of symptoms, location
where the symptoms began, aggravating or alleviating factors, pertinent positives and negatives, other
related diseases, past illnesses, and surgeries or past diagnostic testing related to the present illness.
Medications: (List with reason for med )
PMH
Allergies:
Medication Intolerances:
Chronic Illnesses/Major traumas
Hospitalizations/Surgeries
“Have you ever been told that you have diabetes, HTN, peptic ulcer disease, asthma, lung disease, heart
disease, cancer, TB, thyroid problems, kidney problems, or psychiatric diagnosis?”
Family History
Does your mother, father, or siblings have any medical or psychiatric illnesses? Is anyone diagnosed with:
lung disease, heart disease, HTN, cancer, TB, DM, or kidney disease?
Social History
Education level, occupational history, current living situation/partner/marital status, substance use/abuse,
ETOH, tobacco, and marijuana. Safety status
ROS
General
Weight change, fatigue, fever, chills, night sweats,
and energy level
Cardiovascular
Chest pain, palpitations, PND, orthopnea, and
edema
Skin
Delayed healing, rashes, bruising, bleeding or skin
discolorations, and any changes in lesions or moles
Respiratory
Cough, wheezing, hemoptysis, dyspnea, pneumonia
hx, and TB
Eyes
Corrective lenses, blurring, and visual changes of
any kind
Gastrointestinal
Abdominal pain, N/V/D, constipation, hepatitis,
hemorrhoids, eating disorders, ulcers, and black,
tarry stools
Ears
Ear pain, hearing loss, ringing in ears, and
discharge
Genitourinary/Gynecological
Urgency, frequency burning, change in color of
urine.
Contraception, sexual activity, STDs
Female: last pap, breast, mammo, menstrual
complaints, vaginal discharge, pregnancy hx
Male: prostate, PSA, urinary complaints
Nose/Mouth/Throat
Sinus problems, dysphagia, nose bleeds or
discharge, dental disease, hoarseness, and throat
pain
Musculoskeletal
Back pain, joint swelling, stiffness or pain, fracture
hx, and osteoporosis
Breast
SBE, lumps, bumps, or changes
Neurological
Syncope, seizures, transient paralysis, weakness,
paresthesias, and black-out spells
Heme/Lymph/Endo
HIV status, bruising, blood transfusion hx, night
sweats, swollen glands, increase thirst, increase
hunger, and cold or heat intolerance
Psychiatric
Depression, anxiety, sleeping difficulties, suicidal
ideation/attempts, and previous dx
OBJECTIVE
Weight BMI Temp BP
Height Pulse Resp
General Appearance
Healthy-appearing adult female in no acute distress. Alert and oriented; answers questions appropriately.
Slightly somber affect at first and then brighter later.
Skin
Skin ...
Breast Cancer SOAP noteName Sharon BroomDate Januar
Breast Cancer SOAP note
Name Sharon Broom
Date: January/17/2020.
Age: 45 years old
Gender: Female
Time:12:45
SUBJECTIVE:
Chief Complaint:
“I have a sore lump on the left breast."
History of Present Illness:
Sharon is a 45-year-old female with complaints of a painful lump on her left breast for a month. The patient indicates that she feels unbalanced lumps on her left breast that are painful on the outer and upper corners. The patient observed the areas of the left outer breast worsening in terms of size and pain in the past week. She has experienced the pain of level four out of ten. Her mother was detected to have breast cancer prior to the age of 50. She has had a history of hysterectomy because of irregular periods, menorrhagia. The patient refutes swelling, increased warmth, and redness of the left breast. She repudiates nipple discharge swollen glands, chills, and fever.
History
Past Medical History:
Fibrocystic breast disease, Vitamin D deficiency, Urinary tract infection, Hypothyroidism, Hypocalcemia, and Constipation
Screenings:
Blood Pressure screening (2016 N/A)
Dental Examination (2016 N/A)
Eye Examination (2016 N/A)
Mammogram (2016 BiRad 2)
Pap smear- normal
HPV test- normal
GTPAL: G=1.T=0. P=0. A=0. L=1 (Normal vaginal delivery without complication)
Menstrual Hx: started at the age of 14. Normal PAP outcomes. LMP (cannot recall)-hysterectomy (07.2012)
Post Hospitalizations: Admitted to hospital for hysterectomy for one week
Past Surgical History: Hysterectomy (07. 2012)
Medications:
Armour Thyroid 30mg oral tablet: consume two pills on Monday, Wednesday, and Friday and three pills other days.
Therapy: 15 May 2015
Last Rx: 5 April 2016
Allergies:
Food allergies, Penicillin Triple Sulfa Vaginal CREA
Family History:
The patient’s mother passed away at the age of fifty, with a medical history of breast cancer. Sharon’s father is still alive at the age of seventy, with a medical record of hypertension. The patient has a younger brother aged 35 years and has no medical glitches. The patient has a sixteen-year-old son, who is healthy.
Social History:
The patient is divorced, and she lives with her son. She does not smoke but consumes alcohol irregularly. Sharon takes a regular diet that has no restrictions. She has no worries about weight loss or gains since she exercises two to three times weekly. The patient continually puts on a seatbelt when driving, wears sunscreen.
Sexual/Contraceptive History:
She has not been sexually active for at least a year, but previously, she had a monogamous relation. Birth control: Utilized condoms before. The patient has no fears with sexual performance or feelings.
...
Analyze the subjective portion of the note. List additional inform.docx
Analyze the subjective portion of the note. List additional information that should be included in the documentation.
Analyze the objective portion of the note. List additional information that should be included in the documentation.
Is the assessment supported by the subjective and objective information? Why or why not?
Would diagnostics be appropriate for this case, and how would the results be used to make a diagnosis?
Would you reject/accept the current diagnosis? Why or why not? Identify three possible conditions that may be considered as a differential diagnosis for this patient. Explain your reasoning using at least three different references from current evidence-based literature.
GENITALIA ASSESSMENT
Subjective:
CC: “I have bumps on my bottom that I want to have checked out.”
HPI: AB, a 21-year-old WF college student reports to your clinic with external bumps on her genital area. She states the bumps are painless and feel rough. She states she is sexually active and has had more than one partner during the past year. Her initial sexual contact occurred at age 18. She reports no abnormal vaginal discharge. She is unsure how long the bumps have been there but noticed them about a week ago. Her last Pap smear exam was 3 years ago, and no dysplasia was found; the exam results were normal. She reports one sexually transmitted infection (chlamydia) about 2 years ago. She completed the treatment for chlamydia as prescribed.
PMH: Asthma
Medications: Symbicort 160/4.5mcg
Allergies: NKDA
FH: No hx of breast or cervical cancer, Father hx HTN, Mother hx HTN, GERD
Social: Denies tobacco use; occasional etoh, married, 3 children (1 girl, 2 boys)
Objective:
VS: Temp 98.6; BP 120/86; RR 16; P 92; HT 5’10”; WT 169lbs
Heart: RRR, no murmurs
Lungs: CTA, chest wall symmetrical
Genital: Normal female hair pattern distribution; no masses or swelling. Urethral meatus intact without erythema or discharge. Perineum intact. Vaginal mucosa pink and moist with rugae present, pos for firm, round, small, painless ulcer noted on external labia.
Abd: soft, normoactive bowel sounds, neg rebound, neg murphy’s, negMcBurney
Diagnostics: HSV specimen obtained
Assessment:
Chancre
Episodic/Focused SOAP Note Template
Patient Information:
Initials, Age, Sex, Race
S.
CC
(chief complaint) a BRIEF statement identifying why the patient is here - in the patient’s own words - for instance "headache", NOT "bad headache for 3 days”.
HPI
: This is the symptom analysis section of your note. Thorough documentation in this section is essential for patient care, coding, and billing analysis. Paint a picture of what is wrong with the patient. Use LOCATES Mnemonic to complete your HPI. You need to start EVERY HPI with age, race, and gender (e.g., 34-year-old AA male). You must include the seven attributes of each principal symptom in paragraph form not a list. If the CC was “headache”, the LOCATES for the HPI might look like the following example:
L.
Name Pt. Encounter Number Date Age Sex SUBJ.docx
Name: Pt. Encounter Number:
Date: Age: Sex:
SUBJECTIVE
CC:
Reason given by the patient for seeking medical care “in quotes”
HPI:
Describe the course of the patient’s illness, including when it began, character of symptoms, location
where the symptoms began, aggravating or alleviating factors, pertinent positives and negatives, other
related diseases, past illnesses, and surgeries or past diagnostic testing related to the present illness.
Medications: (List with reason for med )
PMH
Allergies:
Medication Intolerances:
Chronic Illnesses/Major traumas
Hospitalizations/Surgeries
“Have you ever been told that you have diabetes, HTN, peptic ulcer disease, asthma, lung disease, heart
disease, cancer, TB, thyroid problems, kidney problems, or psychiatric diagnosis?”
Family History
Does your mother, father, or siblings have any medical or psychiatric illnesses? Is anyone diagnosed with:
lung disease, heart disease, HTN, cancer, TB, DM, or kidney disease?
Social History
Education level, occupational history, current living situation/partner/marital status, substance use/abuse,
ETOH, tobacco, and marijuana. Safety status
ROS
General
Weight change, fatigue, fever, chills, night sweats,
and energy level
Cardiovascular
Chest pain, palpitations, PND, orthopnea, and
edema
Skin
Delayed healing, rashes, bruising, bleeding or skin
discolorations, and any changes in lesions or moles
Respiratory
Cough, wheezing, hemoptysis, dyspnea, pneumonia
hx, and TB
Eyes
Corrective lenses, blurring, and visual changes of
any kind
Gastrointestinal
Abdominal pain, N/V/D, constipation, hepatitis,
hemorrhoids, eating disorders, ulcers, and black,
tarry stools
Ears
Ear pain, hearing loss, ringing in ears, and
discharge
Genitourinary/Gynecological
Urgency, frequency burning, change in color of
urine.
Contraception, sexual activity, STDs
Female: last pap, breast, mammo, menstrual
complaints, vaginal discharge, pregnancy hx
Male: prostate, PSA, urinary complaints
Nose/Mouth/Throat
Sinus problems, dysphagia, nose bleeds or
discharge, dental disease, hoarseness, and throat
pain
Musculoskeletal
Back pain, joint swelling, stiffness or pain, fracture
hx, and osteoporosis
Breast
SBE, lumps, bumps, or changes
Neurological
Syncope, seizures, transient paralysis, weakness,
paresthesias, and black-out spells
Heme/Lymph/Endo
HIV status, bruising, blood transfusion hx, night
sweats, swollen glands, increase thirst, increase
hunger, and cold or heat intolerance
Psychiatric
Depression, anxiety, sleeping difficulties, suicidal
ideation/attempts, and previous dx
OBJECTIVE
Weight BMI Temp BP
Height Pulse Resp
General Appearance
Healthy-appearing adult female in no acute distress. Alert and oriented; answers questions appropriately.
Slightly somber affect at first and then brighter later.
Skin
Skin.
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 ...
Contraception Essays.docx
This document discusses contraceptive options for a 38-year-old woman. It provides her medical history including asthma, migraines, IBS, and family history of various medical conditions. It notes her physical exam findings and asks additional questions needed to determine the best contraceptive method for her given her medical history and symptoms.
Running head SKIN CONDITIONS AND DIFFERENTIAL DIAGNOSIS 1SKIN.docx
Running head: SKIN CONDITIONS AND DIFFERENTIAL DIAGNOSIS 1
SKIN CONDITIONS AND DIFFERENTIAL DIAGNOSIS 7
Skin Conditions and Differential Diagnosis
Adesola Turner
Walden University
NURS-6512N-17
Advanced Health Assessment.
December 22, 2019.
Introduction
The number 2 graphic (figure below) is characterized as Cherry angiomas that appear in older adults. With time cherry angiomas turn dark, though after infection it is identified by round tiny bright ruby red papules. As age numerically increase Dunphy et al (2015) argues that the disease virtually occurs to everyone above the age of 30 years. One of the ways in which I would perform differential diagnosis is by observing the skin of a patient who is 70 years of age.
Graphic #2
Patient Initials: AB Age: 70 Gender: male
SUBJECTIVE DATA:
Chief Complaint (CC): AB comes in clinic complaining about development of hard red bumps on the chest
History of Present Illness (HPI): Patient AB who is 70 years old comes in the hospital with complaints of having red bumps on his chest that appeared 2 weeks ago. He states that he wants to be done aa physical examination to be performed. AB says that last year he developed at least 4 new bumps on his chest that formed gradually. He is filled with anxiety because upon doing a Google search about his condition, he found that it could some tumors that are developing on his chest. He deniesrefutes any bleeding, painful and itchy bumps, exudation, or any climate variations. The bumps are located around the chest and the abdomen. AB says he has not come into contact with an irritant, denies having a fever, or does he take medications. Also, he reports he is neither under stress nor lifestyle changes. He claims, no one in his family lineage has ever been diagnosed with skin cancer.
Medications: none
Allergies: NKDA
Past Medical History (PMH): identified with stage 4 blood pressure Hypertension and the age of 60 which was well managed.
Past Surgical History (PSH): At age 40, his left shoulder was repaired from a torn rotator cuff.
Sexual/Reproductive History: Married and not sexually active.
Personal/Social History: denies smoking, taking alcohol, substance abuse, or under any influence of ETOH
Immunization History: His immunizations are current. In 2017, he got immunized of Pneumococcal vaccines and influenza vaccine
Significant Family History: Living with no parents who perished from a car accident. Living with his healthy daughter whom he got at his 30s
Social History: Live with her daughter and his 3 grandchildren. Being a widow for 8 years, he has been working as an engineer before he retired. In his free time, he does light exercises. Every day he attends catholic mass and then joins his 6 friends for breakfast at the local diner.
Review of Systems (ROS):
General: Mr. AB is a well-organized and neat man. He is alert and corporate during the discussion. He responds t ...
Bacterial Vaginosis Zahavah is a 16 years Gender Female Race .docx
Bacterial Vaginosis
Zahavah is a 16 years Gender: Female Race: non-Hispanic White Diagnosis: bacterial vaginosis Subjective Data: HJ is a 16-year-old Hispanic female patient who presented to the office with her mother with a two week history of severe irritation and soreness of her vulva. The patient reported of having a two-week history of burning sensation on passing urine without increased urinary frequency. In addition, the patient complained of having a thick, creamy-white vaginal discharge. She had normal and regular menstrual periods. She agreed to having multiple sexual partners for the last one year since breaking up with her high school boyfriend. She denied taking medications in the management of the issue of concern. Objective Data: Vital signs; BP 110/76, HR 78, RR 26, temperature 98, and an oxygen saturation of 99 percent on room air. In general, HJ was a healthy lad who was well oriented to place, time, and person, without obvious distress. HEENT without issues of concern. On respiratory assessment, the patient had a clear and normal lung sounds bilaterally without crackles and wheezes. Cardiovascular assessment showing normal heart sound without murmurs and gallops. Normal bowel sounds on all quadrants on gastrointestinal examination. Patient denied to have a physical examination on the perineal area. Assessment: History of presenting illness indicating a possible bacterial vaginosis. Positive Whiff test indicating bacterial vaginosis. Plan of care: Clindamycin 300 mg orally twice daily for 7 days was prescribed to help in the management of the issues. Patient educated on the need to avoid multiple sexual partners to avoid reoccurrence of the issue as well as possible sexually transmitted diseases.
Answer below QUESTION
· Subjective: What details did the patient or parent provide regarding the personal and medical history? Include any discrepancies between the details provided by the child and details provided by the parent as well as possible reasons for these discrepancies.
· Objective: What observations did you make during the physical assessment? Include pertinent positive and negative physical exam findings. Describe whether the patient presented with any growth and development or psychosocial issues.
· Assessment: What were your differential diagnoses? Provide a minimum of three possible diagnoses. List them from highest priority to lowest priority and include their ICD-10 code for the diagnosis. What was your primary diagnosis and why?
· Plan: What was your plan for diagnostics and primary diagnosis? What was your plan for treatment and management? Include pharmacologic and non-pharmacologic treatments, alternative therapies, and follow-up parameters as well as a rationale for this treatment and management plan.
· Reflection notes: What was your “aha” moment? What would you do differently in a similar patient evaluation?
Note: Your Focused Note Assignment must be signed by Day 7 of Week 3.
PRAC 6541:
.
Physical diagnosis
The 85-year-old male patient presented with progressive forgetfulness, weight loss, and depressed mood over the past year since his wife's death. His daughter observed a decline in his ability to recall recent events, directions, and names. Alzheimer's disease is the primary consideration given his age and symptoms consistent with typical memory loss and cognitive decline seen in Alzheimer's. Differential diagnoses considered include delirium, depression, and hypothyroidism but were deemed less likely based on aspects of his history and presentation that did not fully match these conditions.
History and PE
The 85-year-old male patient presented with progressive forgetfulness, weight loss, and depressed mood over the past year since his wife's death. His daughter observed deterioration in his memory, concentration, and ability to carry on conversations. Alzheimer's disease is the primary consideration given his age and symptom progression. Differential diagnoses considered include delirium, depression, and hypothyroidism but were deemed less likely based on aspects of his clinical presentation and history.
3 history taking & physical examination
This document provides information on nursing history taking and physical examination. It discusses the importance of obtaining an accurate patient history, which is critical for diagnosis. The key components of history taking are identified as demographic data, chief complaint, history of present illness, past medical history, family history, drug history, review of systems, and physical examination. The principles and techniques of physical examination are outlined, including inspection, palpation, percussion, and auscultation. A head-to-toe assessment approach is recommended to perform a thorough physical exam.
Comprehensive SOAP TemplateThis template is for a full history.docx
Comprehensive SOAP Template
This template is for a full history and physical. For this course include only areas that are related to the case.
Patient Initials: _______
Age: _______
Gender: _______
Note: The mnemonic below is included for your reference and should be removed before the submission of your final note.
O = onset of symptom (acute/gradual)
L= location
D= duration (recent/chronic)
C= character
A= associated symptoms/aggravating factors
R= relieving factors
T= treatments previously tried – response? Why discontinued?
S= severity
SUBJECTIVE DATA: Include what the patient tells you, but organize the information.
Chief Complaint (CC): In just a few words, explain why the patient came to the clinic.
History of Present Illness (HPI): This is the symptom analysis section of your note. Thorough documentation in this section is essential for patient care, coding, and billing analysis. Paint a picture of what is wrong with the patient. You need to start EVERY HPI with age, race, and gender (e.g., 34-year-old AA male). You must include the seven attributes ofeach principal symptom in paragraph form not a list:
1. Location
2. Quality
3. Quantity or severity
4. Timing, including onset, duration, and frequency
5. Setting in which it occurs
6. Factors that have aggravated or relieved the symptom
7. Associated manifestations
Medications: Include over-the-counter, vitamin, and herbal supplements. List each one by name with dosage and frequency.
Allergies: Include specific reactions to medications, foods, insects, and environmental factors. Identify if it is an allergy or intolerance.
Past Medical History (PMH): Include illnesses (also childhood illnesses), hospitalizations.
Past Surgical History (PSH): Include dates, indications, and types of operations.
Sexual/Reproductive History: If applicable, include obstetric history, menstrual history, methods of contraception, sexual function, and risky sexual behaviors.
Personal/Social History: Include tobacco use, alcohol use, drug use, patient’s interests, ADL’s and IADL’s if applicable, and exercise and eating habits.
Immunization History: Includelast Tdap, Flu, pneumonia, etc.
Significant Family History: Include history of parents, grandparents, siblings, and children.
Lifestyle: Include cultural factors, economic factors, safety, and support systems and sexual preference.
Review of Systems: From head-to-toe, include each system that covers the Chief Complaint, History of Present Illness, and History (this includes the systems that address any previous diagnoses).Remember that the information you include in this section is based on what the patient tells you so ensure that you include all essentials in your case (refer to Chapter 2 of the Sullivan text).
General: Include any recent weight changes, weakness, fatigue, or fever, but do not restate HPI data here.
HEENT:
Neck:
Breasts:
Respiratory:
Cardiovascular/Peripheral Vascular:
Gastrointestinal:
Genitourinary:
Mu.
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.
SOAO NotePatient Initials S.MPt. Encounter Number 2 .docx
SOAO Note
Patient Initials: S.M
Pt. Encounter Number: 2
Date: 10/12/2020
Age: 61
Sex: Female
Allergies: NKA
Advanced Directives: No
SUBJECTIVE
Chief Complaint: "I have a lump on my right breast."
HPI: S.M is a 61-year-old, Hispanic, female who presents to the office alarmed by a painful lump in her right breast that she discovered while showering. S.M reports the pain started 2 days ago while in the shower. The pain is felt when touching the right breast, and it felt on light touch. Current pain level is now 5/10. She does not report any skin changes. Patient denies any history of herbal medicine use and is currently on no medication. Pain gets worse with movement and with lifting weight. Pain is relieved with rest and medication. S.M gets some short relief with pain reliever ibuprofen 200mg that she takes twice a day for the past two days.
Past Medical History
Medication Intolerances: No known drug intolerance
Chronic Illnesses/Major traumas: The patient denies any history of major trauma.
Screening Hx/Immunizations Hx: last mammogram, which was normal, was 2 years ago.
OBGYN: Menarche at 10; LMP 2 weeks ago; last PAP 2019/Normal; GTPAL: 11001 score; no previous history of STDs. S.M is sexually active, have had 2 sexual partners in the past. S.M used condoms with previous partners. No previous gyn diagnoses or procedures done in the past.
Hospitalizations/Surgeries: Hospitalized once for delivery
Family History: There is no history of malignancy in first-degree relatives. She has one sister, age 58, who is in good health. Mother died at age 70; father died at age 64, from unknown causes.
Social History: S.M is married with one child. No use of alcohol; drinks wine socially; drinks one cup of coffee sometime to start her day at work. Never uses drugs.
Review of System
Constitutional: No significant gain/loss weight, no chills, no malaise or fatigue; no night sweats, no exercise intolerance. She does not report any skin changes. She has not experienced fever, weight loss, headache, nausea, vomiting, dizziness, or bone pain.
Skin: Denies rashes, pigmentation changes, lesions, or hair or nail changes.
Eyes: denies vision changes, diplopia, blurred vision, reports wearing eyeglasses.
Ears: Denies loss of hearing, ear pain, drainage, sensation of ears feeling full, ringing in the ear, or ear trauma.
Nose/Mouth/Throat: Denies sore throat, hoarseness, difficulty swallowing, postnasal
drip. No report of mouth or lips sore, bleeding gums, ulcerations or lesions of tongue or
mucosa; no dentures or dental appliances, or missing teeth reported.
Breast: Refers to right breast pain, or discomfort to right breast. Reports some brownish nipple discharges when squeezing the nipple and denies any breast trauma.
Heme/Lymph/Endo: Denies history of anemia, no bruising, no abnormal bleeding, and no swollen glands.
Cardiovascular: Denies chest pain, palpitations, orthopnea, edema, claudicati.
Nursing case presentation
The document provides information about a 47-year-old male patient diagnosed with laryngeal cancer. It discusses the patient's history of hoarseness of voice, difficulty breathing, and a neck mass that has grown over several years. Laboratory results show low albumin, globulin, LDL, and HDL levels indicating malnutrition and inflammation. A physical exam finds lesions on the tracheostomy site and crackles in the lungs. The patient has a history of smoking and drinking alcohol daily for 30 years which are risk factors for his cancer diagnosis.
Physical diagnosis
The document provides guidelines for performing a pediatric clinical diagnosis, including taking a thorough patient history, conducting a full physical examination involving multiple body systems, and documenting findings. The physical exam section details how to assess things like vital signs, growth measurements, skin appearance, and examination of specific organ systems like heart, lungs, abdomen, and musculoskeletal system.
Comment by Morgan, Dorothy Tali Do not forget to include a runni
Comment by Morgan, Dorothy Tali: Do not forget to include a running head to follow APA guidelines
Health History
Yensi Aguilar
Benjamin Leon School of nursing
NUR1060C: Adult Health Assessment
Professor Dorothy Morgan
April 7, 2021
Health History
Identifying data
Date of history: 28/02/2021
Examiner: Yensi Aguilar
Name: L.P.
Address: 3403 SW 6h Street
Phone Number: 786-597-3071
Age:46
Sex: Female
Race: White
Place of Birth: Honduras
Marital Status: Married
Significant Other: Husband
Occupation: Teacher
Religion: Christian
Primary Language: Spanish
Secondary Language: English
Source of referral: The patient found the hospital’s address on the internet
Source of history: Documents with the patient’s health history gave information concerning the patient. The patient also talked concerning her health status.
Reliability: Currently, the patient seems to have a stable mental and physical state.
Chief Complaints/Reasons for Visit: According to the patient, she started experiencing high fever, blood-stained sputum, night sweats, coughing, and weight loss.
Present Illness
Time of onset: according to the patient, she started experiencing symptoms two weeks ago.
Type of onset: The patient says that she started by occasionally sweating, mild cough, headache, and pain in the abdomen area. Over time, these conditions became severe.
Original Source: The patient complains of pain in her chest and respiratory tract.
Severity: During the day, the patient does not feel many discomforts, but it becomes worse at night due to lower temperatures. Hence, the condition does not deter the patient from executing tasks during the day. The severity of her state is at 5 out of 10 on a 0-to-10-point scale.
Radiation: At night, the patient feels severe pain throughout her chest region
Time Relationship: At first, this condition was still developing and was easy to handle. However, it has evolved and has gotten worse.
Duration: It has been two weeks since the patient started experiencing the symptoms.
Association: The symptoms experienced by the patient are similar to those of flu.
Source of Relief: According to the patient, she feels better when resting after doing some light physical exercise.
Source of Aggravation: The symptoms become worse during the night. Again, exposure to allergens such as dust or cold increases the symptom’s severity.
Past History
General State of Health: The patient’s general condition is fair, considering she is suffering from a chronic illness.
Childhood Illnesses: She suffered from smallpox and measles as a child
Adult Illnesses: Hypertension, Anemia, and asthma
Psychiatric Illnesses: She has experienced mild depression in the past
Accidents and Injuries: Never had an accident or injuries
Operations: The patient denies any surgical operations
Hospitalizations: After visiting the hospital, the patient got an admission to the Jackson Hospital for one week to undergo treatment for asthma and hyper ...
SOAP NotePatient Initials RA Pt. Encounter Number .docx
SOAP Note
Patient Initials: RA Pt. Encounter Number: 1
Date: 10/1/20 Age: 23 Sex: female
Allergies: NKA Advanced Directives: none
SUBJECTIVE
CC: “I have been having heavy periods for 4-5 months now. I feel tired and dizzy most days”
HPI: 23-year-old came to the clinic today complaining of heavy menstrual periods happening for the past 4 to 5 months. Accompanying the heavy flow, patient states that she has moderate cramps. Pt describes the pain as stabbing and its 3 out of the 0-10 scale. Patient does not take any medications for the pain. The pain is decreased by applying warm compresses to the lower abdominal area. In addition, patient complains of feeling dizziness and tiredness most of the times.
Current Medications: none
PMH Medication Intolerances: NONE Chronic Illnesses/Major traumas: NONE Screening Hx/Immunizations Hx: Vaccinations up to date, most recent pap smear 12/19 – negative Hospitalizations/Surgeries: None
Family History:Father: Alive, No medical history Mother: Alive, Htn
Social History: Patient is a full-time college student and part time employee at Publix as cashier. Pt lives at home with parents and denies having had a sexual partner for the past year. Patient denies the use of cigars, alcohol, or illegal drugs.
ROS
GeneralDenies recent weight loss, fever, change in appetite or headaches. She denies chills or night sweats. CardiovascularDenies palpitations, chest pain, orthopnea, and claudication. Reports episodes of hypotension.
SkinDenies bruising, skin rash, or discoloration. Denies changes in moles or skin breakdown. RespiratoryDenies shortness of breath, abnormal sputum, cough, or wheezing.
EyesDenies pain, redness, loss of vision, double or blurred vision GastrointestinalDenies abdominal pain, decreased appetite, nausea, or vomiting. Denies food intolerances and changes in stool
EarsDenies ear pain, ear infections, or tinnitus Genitourinary/GynecologicalDenies dysuria, flank pain, and hematuria. Denies abnormal vaginal discharge or itching. Denies STI history. Reports heavy menstrual periods lasting 5 to 6 days, associated with cramping; every 28 days. OBSTETRIC/GYNECOLOGICAL Hx:Menarche: 11 years LMP: 09/15/20 G 0 T 0 P 0 A 0 L 0 Birth Control/Type: NoneMenopause: no Sexually Active: yes STD Hx: None
Nose/Mouth/ThroatDenies nasal pain, congestion, epistaxis, or postnasal drip. Denies pain in mouth, bleeding gums, or dry mouth. Denies pain in throat, hoarseness, difficulty or painful swallowing. MusculoskeletalDenies muscle pain or joint pain. Denies limited range of motion
BreastDenies breast tenderness, discharge, redness, or lumps. NeurologicalDenies headache, dizziness, seizures, or memory loss.
Heme/Lymph/EndoPt denies bruising PsychiatricDenies mood changes, irritability, or changes in concentration. Denies hav.
History taking - For Surgical patients
This PPT is based on taking history from surgical patients for UG - Students. ( Based on History taking methods adopted by S.Das )
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.
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.
Copyright © 2015 by Mosby, an imprint of Elsevier Inc.x-3
Copyright © 2015 by Mosby, an imprint of Elsevier Inc.
x-3
Student Checklist
Ball: Seidel’s Guide to Physical Examination, 8th Edition
Chapter 05: Mental Status
Student Checklist
Adult Examination Checklist
Mark data, when appropriate, to indicate the following:
If normal, * if abnormal, O if absent.
Subjective Data
__Alertness
__Emotional status
__Orientation
__Time
__Place
__Person
__Analogies (similarities)
__Abstract reasoning (fable, proverb)
__Arithmetic calculations
__Writing ability
__Motor skills
__Memory
__Immediate
__Recent
__Remote
__Attention span (short commands)
__Judgment/decision making (hypothetical situation)
__Voice
__Quality
__Pace
__Loudness
__Articulation
__Comprehension
__Coherence (perceptions clearly conveyed)
__Mood and feelings
__Thought processes (logical)
__Perceptual distortions (hallucinations)
Objective Data
Observation
__Alertness
__Grooming
__Body language
__Emotional status
__Attention span
__Coherence
__Voice
__Quality
__Pace
__Loudness
__Articulation
__Comprehension
__Mood and feelings
__Thought processes
__Perceptual distortions
Testing
__Orientation
__Time
__Place
__Person
__Analogies
__Abstract reasoning
__Arithmetic calculations
__Writing ability
__Motor skills
__Memory
__Immediate
__Recent
__Remote
__Attention span
5-2
Student Checklist
Copyright © 2015 by Mosby, an imprint of Elsevier Inc.
Copyright © 2015 by Mosby, an imprint of Elsevier Inc.
Copyright © 2011 by Mosby, Inc., an affiliate of Elsevier Inc.
Detail those data marked as abnormal:
Episodic/Focused SOAP Note Template
Patient Information:
Initials, Age, Sex, Race
S.
CC (chief complaint) a BRIEF statement identifying why the patient is here - in the patient’s own words - for instance "headache", NOT "bad headache for 3 days”.
HPI: This is the symptom analysis section of your note. Thorough documentation in this section is essential for patient care, coding, and billing analysis. Paint a picture of what is wrong with the patient. Use LOCATES Mnemonic to complete your HPI. You need to start EVERY HPI with age, race, and gender (e.g., 34-year-old AA male). You must include the seven attributes of each principal symptom in paragraph form not a list. If the CC was “headache”, the LOCATES for the HPI might look like the following example:
Location: head
Onset: 3 days ago
Character: pounding, pressure around the eyes and temples
Associated signs and symptoms: nausea, vomiting, photophobia, phonophobia
Timing: after being on the computer all day at work
Exacerbating/ relieving factors: light bothers eyes, Aleve makes it tolerable but not completely better
Severity: 7/10 pain scale
Current Medications: include dosage, frequency, length of time used and reason for use; also include OTC or homeopathic products.
Allergies: include medication, food, and environmental allergies separately (a description of what the allergy is ie angioedema, anaphylaxis, etc. This will help determine a true reaction vs intolerance).
PMHx: inc ...
Antenatal care
The document outlines the components and process of antenatal care, which includes screening for high-risk cases, educating mothers on pregnancy and delivery, and ensuring a healthy pregnancy and delivery for both mother and baby. Antenatal care involves taking a medical history, conducting physical and obstetric examinations including measuring fundal height and fetal position, performing lab tests, and providing health education and immunizations. The goal of antenatal care is to monitor for and treat any complications in order to result in a normal pregnancy and delivery of a healthy baby from a healthy mother.
Internal medicine
The document provides an overview and examples of various note formats used in internal medicine, including formats for history and physical exams, progress notes, admission and discharge orders, and specialty notes. It includes mnemonics, equations, and classifications to guide note writing. The document aims to familiarize medical students with the structure and components of different types of notes commonly written in internal medicine.
internal medicine.pdf
The document provides an overview and examples of various note formats used in internal medicine, including formats for history and physical exams, progress notes, admission and discharge orders, and specialty notes. It includes mnemonics, equations, and classifications to guide documentation. Sections cover topics such as cardiology, gastroenterology, pulmonary medicine, and intensive care unit notes.
PEDIATRIC FILLABLE SOAP NOTE TEMPLATE PEDIATRIC FILLABLE SOAP NO.docx
PEDIATRIC FILLABLE SOAP NOTE TEMPLATE
PEDIATRIC FILLABLE SOAP NOTE TEMPLATE
PEDIATRIC FILLABLE SOAP NOTE TEMPLATE
STUDENT NAME:
DATE OF ASSIGNMENT: 05/11/2020
Patient Initials: J.T.
Date of Encounter: 05/06/2020
Sex: Male
Age/DOB/Place of Birth: 12yo, DOB: 05/03/2008, Miami, FL
SUBJECTIVE
Historian: Patient J.T.
Present Concerns/CC: “My throat has been hurting recently”
Reason given by the patient for seeking medical care “in quotes”
Child Profile: (Sexual History (If appropriate); ADLs (age appropriate); Safety Practices; Changes in daycare/school/after-school care;
Sports/physical activity; Developmental Hx)
Patient is sexually inactive, a student at a local middle school, spends his time at home due to the COVID-19 pandemic, otherwise he enjoys playing videogames with his friends all day. The patient spends all of his time at home recently due to the pandemic but would otherwise go out with her family and friends sometimes.
HPI: (must include all components - OLD CARTS)
Patients throat began to hurt 2 days ago. It worsened over the past day, but he states that it is now around the same as yesterday. He states that he can still swallow food and drink, but it hurts when it passes his throat. It is present at all times of day, from when he wakes up, to when he goes to bed. The pain is localized at the back of this throat. It is dull and described as a 3/10. His mother has given him a honey and lime mixture that he states helps for a short while.
Medications: (List with reason for meds)
Patient not currently taking any medication
PMH:
Allergies: Dog hair, cat hair
Medication Intolerances:
None
Chronic Illnesses/Major traumas:
None
Hospitalizations/Surgeries:
None
Immunizations: All vaccines up to date with the exception of the most recent influenza vaccine.
Family History (please identify all immediate family)
Mother: 32 years old, no current health problems
Father: 34 years old, no current health problems
Social History (Education level, occupational history, current living situation/partner/marital status, substance use/abuse, ETOH, tobacco, and marijuana. Safety status)
Middle school student. Does not work. Lives with his parents and 2 brothers, one 6, the other 2 years old. Parents are married. Does not drink alcohol. Does not use recreational drugs, does not use tobacco products, does not smoke, does not vape. The patient states feeling safe at home with his family.
Review of Systems (ROS)
General
Denies fevers, chills, nausea, and vomiting
Cardiovascular
Denies chest pain, pressure, palpitations
Skin
Denies lesions, itching, or redness.
Respiratory
Denies shortness of breath, denies cough, denies difficulty breathing
Eyes
Denies blurred vision, denies visual loss, denies double vision
Gastrointestinal
Denies nausea and vomiting, denies abdominal pain, denies diarrhea, and bloody stools.
Ears
Denies hearing loss, pain, or dra.
Health assessment
The document discusses the components and process of community health assessment by nurses. It begins by defining health assessment as a systematic process of collecting and analyzing data about clients through interaction with them and other providers. The key components of assessment are history taking, physical examination, and review of systems. Specific techniques for physical exams are also outlined. The document then discusses health assessment for different age groups - infants, preschoolers, school-aged children, adults, and elders. It provides details on what to assess for each group, including growth standards. The overall goal of community health assessment is early detection of issues and providing preventative education.
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 ...
Journeys of Paul REL3034.E1Assignment OneWrite about half.docx
Journeys of Paul REL3034.E1
Assignment One
Write about half a page each, single spaced (10 points each). Mention any resources you draw from.
0. Discuss what it meant to be a Roman citizen in Paul’s day. How were citizens better off than the slave class?
0. Summarize Saul’s conversion experience and how he describes himself in various New Testament texts. In what ways do you see this as a dramatic life change?
0. Who was Barnabas? List and detail his appearances in the Book of Acts. Describe his importance in assisting Paul to get acquainted with Christians.
0. Discuss social, political, and religious factors that contributed to the rapid spread of Christianity during the first century.
Paul
ApostleoftheHeatSetFree
‘WheretheSpiritoftheLordis,theretheheartisfree’
(2Corinthians3:17,BasicEnglishVersion)
F.F.Bruce
DIGITALLIBRARY
Copyright©1977F.F.Bruce
Firstpublished1977byPaternoster
Revised(second)Edition1980
ThisDigitalEdition2005
PaternosterisanimprintofAuthenticMedia,
9HoldomAvenue,Bletchley,
MiltonKeynes,MK11QR,UK.
and
P.O.Box1047,Waynesboro,
GA,3080-2047,U.S.A.
TherightofF.F.BrucetobeidentifiedastheAuthorofthisWorkhasbeenasserted
inaccordancewithCopyright,DesignsandPatentsAct1988.
Allrightsreserved.Nopartofthispublicationmaybereproduced,storedina
retrievalsystem,ortransmittedinanyformorbyanymeans,electric,mechanical,
photocopying,recordingorotherwise,withoutthepriorpermissionofthepublisher
oralicensepermittingrestrictedcopying.IntheU.K.suchlicensesareissuedbythe
CopyrightLicensingAgency,90TottenhamCourtRoad,LondonW1P9HE.
BritishLibraryCataloguinginPublicationData
aCataloguerecordforthisbookis
availablefromtheBritishLibrary
ISBN1-84227-302-7
TOMYGRAND-DAUGHTERS
HELEN,ANNA,ESTHERANDWINONAMARY
ANDMYGRANDSONS
PETER,FREDERICK,ALANANDPAUL
bearinginmindT.R.Glover’scommentonaRomanEmperor’s
condemnationoftheApostletotheGentiles—thatthedaywas
tocomewhenmenwouldcalltheirdogsNeroandtheirsons
PAUL
Contents
Preface
Abbreviations
Introduction
1.TheRiseofRome
2.TheJewsunderForeignRule
3.“OfNoMeanCity”
4.“ThisManisaRomanCitizen”
5.“AHebrewBornofHebrews”
6.“WhentheTimehadFullyCome”
7.TheBeginningof“TheWay”
8.PersecutoroftheChurch
9.PaulBecomesaChristian
10.PaulandtheJerusalemTradition
11.PaulandtheHistoricalJesus
12.PaulandtheExaltedChrist
13.PaulandtheHellenisticMission
14.ManofVisionandManofAction
15.ConferenceinJerusalem
16.ChurchExtensioninCyprusandAsiaMinor
17.TheGentileProblem
18.“WhattheLawcouldnotdo”
19.FleshandSpirit
20.AntiochtoPhilippi
21.ChristianityinThessalonica
22.PaulandtheAthenians
23.TheChurchofGodatCorinth
24.CorinthianCorrespondence
25.BaptismandtheLord’sSupperinPaulineThought
26.Ephesus:OpenDoorandManyAdversaries
27.PaulandtheLifetoCome
28.FarewelltoMacedoniaandAchaia
29.TheGospelaccordingtoPaul
30.LastVisittoJerusalem
31.CaesareaandtheAppealtoCaesar
32.“AndSoWeCametoRome”
33.PaulandRomanChristianity
34.TheLettertoPhilemon
35.PrincipalitiesandPowers.
JW House FundraiserJourney Through the Enchanted Forest Ga.docx
JW House Fundraiser
Journey Through the Enchanted Forest Gala
Silent Auction
Table Decor
Specialized cocktails for Event
Three Screens will be Placed for Optimum Viewing by all Attendees
New House Announcement
Happy 30th Birthday, JW!
Auction
Isle down Center Allows Fundraising Auctioneer to Engage Audience
Balloon
Drop
S’mores Sponsored by Largest Corporate Donor
Finish the Evening with Dancing & Beverages
Image Sources
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1. INTRODUCTION. Begin by stating what you will discuss and explain why is important.
2. CRITICAL SUMMARY. Summarize the relevant views and the arguments that you believe are important.
Usually in a critical discussion it is not sufficient to merely summarize the author’s view. Your attention should be
focused on the author's development of the view--that is, on his arguments, in the broadest sense of the word.
3. CARE IN CITATIONS. Make sure you accurately state the position of the author and always include page
references for each quotation or attribution to her/him if applicable.
4. CRITICAL EVALUATION FROM A CHRISTIAN PERSPECTIVE. At least half of your paper must be devoted
to a critical evaluation of the views of the author you are discussing from the perspective of the Christian thesis that
a Christian call in business may prop-up the role of the markets.
5. CONSIDER POSSIBLE RESPONSES TO YOUR OBJECTIONS. Whenever you offer an objection to an
author's position, explicitly consider whether the author has said anythin.
More Related Content
Similar to Name Pt. Encounter Number Date Age Sex SUBJ.docx
Physical diagnosis
The 85-year-old male patient presented with progressive forgetfulness, weight loss, and depressed mood over the past year since his wife's death. His daughter observed a decline in his ability to recall recent events, directions, and names. Alzheimer's disease is the primary consideration given his age and symptoms consistent with typical memory loss and cognitive decline seen in Alzheimer's. Differential diagnoses considered include delirium, depression, and hypothyroidism but were deemed less likely based on aspects of his history and presentation that did not fully match these conditions.
History and PE
The 85-year-old male patient presented with progressive forgetfulness, weight loss, and depressed mood over the past year since his wife's death. His daughter observed deterioration in his memory, concentration, and ability to carry on conversations. Alzheimer's disease is the primary consideration given his age and symptom progression. Differential diagnoses considered include delirium, depression, and hypothyroidism but were deemed less likely based on aspects of his clinical presentation and history.
3 history taking & physical examination
This document provides information on nursing history taking and physical examination. It discusses the importance of obtaining an accurate patient history, which is critical for diagnosis. The key components of history taking are identified as demographic data, chief complaint, history of present illness, past medical history, family history, drug history, review of systems, and physical examination. The principles and techniques of physical examination are outlined, including inspection, palpation, percussion, and auscultation. A head-to-toe assessment approach is recommended to perform a thorough physical exam.
Comprehensive SOAP TemplateThis template is for a full history.docx
Comprehensive SOAP Template
This template is for a full history and physical. For this course include only areas that are related to the case.
Patient Initials: _______
Age: _______
Gender: _______
Note: The mnemonic below is included for your reference and should be removed before the submission of your final note.
O = onset of symptom (acute/gradual)
L= location
D= duration (recent/chronic)
C= character
A= associated symptoms/aggravating factors
R= relieving factors
T= treatments previously tried – response? Why discontinued?
S= severity
SUBJECTIVE DATA: Include what the patient tells you, but organize the information.
Chief Complaint (CC): In just a few words, explain why the patient came to the clinic.
History of Present Illness (HPI): This is the symptom analysis section of your note. Thorough documentation in this section is essential for patient care, coding, and billing analysis. Paint a picture of what is wrong with the patient. You need to start EVERY HPI with age, race, and gender (e.g., 34-year-old AA male). You must include the seven attributes ofeach principal symptom in paragraph form not a list:
1. Location
2. Quality
3. Quantity or severity
4. Timing, including onset, duration, and frequency
5. Setting in which it occurs
6. Factors that have aggravated or relieved the symptom
7. Associated manifestations
Medications: Include over-the-counter, vitamin, and herbal supplements. List each one by name with dosage and frequency.
Allergies: Include specific reactions to medications, foods, insects, and environmental factors. Identify if it is an allergy or intolerance.
Past Medical History (PMH): Include illnesses (also childhood illnesses), hospitalizations.
Past Surgical History (PSH): Include dates, indications, and types of operations.
Sexual/Reproductive History: If applicable, include obstetric history, menstrual history, methods of contraception, sexual function, and risky sexual behaviors.
Personal/Social History: Include tobacco use, alcohol use, drug use, patient’s interests, ADL’s and IADL’s if applicable, and exercise and eating habits.
Immunization History: Includelast Tdap, Flu, pneumonia, etc.
Significant Family History: Include history of parents, grandparents, siblings, and children.
Lifestyle: Include cultural factors, economic factors, safety, and support systems and sexual preference.
Review of Systems: From head-to-toe, include each system that covers the Chief Complaint, History of Present Illness, and History (this includes the systems that address any previous diagnoses).Remember that the information you include in this section is based on what the patient tells you so ensure that you include all essentials in your case (refer to Chapter 2 of the Sullivan text).
General: Include any recent weight changes, weakness, fatigue, or fever, but do not restate HPI data here.
HEENT:
Neck:
Breasts:
Respiratory:
Cardiovascular/Peripheral Vascular:
Gastrointestinal:
Genitourinary:
Mu.
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.
SOAO NotePatient Initials S.MPt. Encounter Number 2 .docx
SOAO Note
Patient Initials: S.M
Pt. Encounter Number: 2
Date: 10/12/2020
Age: 61
Sex: Female
Allergies: NKA
Advanced Directives: No
SUBJECTIVE
Chief Complaint: "I have a lump on my right breast."
HPI: S.M is a 61-year-old, Hispanic, female who presents to the office alarmed by a painful lump in her right breast that she discovered while showering. S.M reports the pain started 2 days ago while in the shower. The pain is felt when touching the right breast, and it felt on light touch. Current pain level is now 5/10. She does not report any skin changes. Patient denies any history of herbal medicine use and is currently on no medication. Pain gets worse with movement and with lifting weight. Pain is relieved with rest and medication. S.M gets some short relief with pain reliever ibuprofen 200mg that she takes twice a day for the past two days.
Past Medical History
Medication Intolerances: No known drug intolerance
Chronic Illnesses/Major traumas: The patient denies any history of major trauma.
Screening Hx/Immunizations Hx: last mammogram, which was normal, was 2 years ago.
OBGYN: Menarche at 10; LMP 2 weeks ago; last PAP 2019/Normal; GTPAL: 11001 score; no previous history of STDs. S.M is sexually active, have had 2 sexual partners in the past. S.M used condoms with previous partners. No previous gyn diagnoses or procedures done in the past.
Hospitalizations/Surgeries: Hospitalized once for delivery
Family History: There is no history of malignancy in first-degree relatives. She has one sister, age 58, who is in good health. Mother died at age 70; father died at age 64, from unknown causes.
Social History: S.M is married with one child. No use of alcohol; drinks wine socially; drinks one cup of coffee sometime to start her day at work. Never uses drugs.
Review of System
Constitutional: No significant gain/loss weight, no chills, no malaise or fatigue; no night sweats, no exercise intolerance. She does not report any skin changes. She has not experienced fever, weight loss, headache, nausea, vomiting, dizziness, or bone pain.
Skin: Denies rashes, pigmentation changes, lesions, or hair or nail changes.
Eyes: denies vision changes, diplopia, blurred vision, reports wearing eyeglasses.
Ears: Denies loss of hearing, ear pain, drainage, sensation of ears feeling full, ringing in the ear, or ear trauma.
Nose/Mouth/Throat: Denies sore throat, hoarseness, difficulty swallowing, postnasal
drip. No report of mouth or lips sore, bleeding gums, ulcerations or lesions of tongue or
mucosa; no dentures or dental appliances, or missing teeth reported.
Breast: Refers to right breast pain, or discomfort to right breast. Reports some brownish nipple discharges when squeezing the nipple and denies any breast trauma.
Heme/Lymph/Endo: Denies history of anemia, no bruising, no abnormal bleeding, and no swollen glands.
Cardiovascular: Denies chest pain, palpitations, orthopnea, edema, claudicati.
Nursing case presentation
The document provides information about a 47-year-old male patient diagnosed with laryngeal cancer. It discusses the patient's history of hoarseness of voice, difficulty breathing, and a neck mass that has grown over several years. Laboratory results show low albumin, globulin, LDL, and HDL levels indicating malnutrition and inflammation. A physical exam finds lesions on the tracheostomy site and crackles in the lungs. The patient has a history of smoking and drinking alcohol daily for 30 years which are risk factors for his cancer diagnosis.
Physical diagnosis
The document provides guidelines for performing a pediatric clinical diagnosis, including taking a thorough patient history, conducting a full physical examination involving multiple body systems, and documenting findings. The physical exam section details how to assess things like vital signs, growth measurements, skin appearance, and examination of specific organ systems like heart, lungs, abdomen, and musculoskeletal system.
Comment by Morgan, Dorothy Tali Do not forget to include a runni
Comment by Morgan, Dorothy Tali: Do not forget to include a running head to follow APA guidelines
Health History
Yensi Aguilar
Benjamin Leon School of nursing
NUR1060C: Adult Health Assessment
Professor Dorothy Morgan
April 7, 2021
Health History
Identifying data
Date of history: 28/02/2021
Examiner: Yensi Aguilar
Name: L.P.
Address: 3403 SW 6h Street
Phone Number: 786-597-3071
Age:46
Sex: Female
Race: White
Place of Birth: Honduras
Marital Status: Married
Significant Other: Husband
Occupation: Teacher
Religion: Christian
Primary Language: Spanish
Secondary Language: English
Source of referral: The patient found the hospital’s address on the internet
Source of history: Documents with the patient’s health history gave information concerning the patient. The patient also talked concerning her health status.
Reliability: Currently, the patient seems to have a stable mental and physical state.
Chief Complaints/Reasons for Visit: According to the patient, she started experiencing high fever, blood-stained sputum, night sweats, coughing, and weight loss.
Present Illness
Time of onset: according to the patient, she started experiencing symptoms two weeks ago.
Type of onset: The patient says that she started by occasionally sweating, mild cough, headache, and pain in the abdomen area. Over time, these conditions became severe.
Original Source: The patient complains of pain in her chest and respiratory tract.
Severity: During the day, the patient does not feel many discomforts, but it becomes worse at night due to lower temperatures. Hence, the condition does not deter the patient from executing tasks during the day. The severity of her state is at 5 out of 10 on a 0-to-10-point scale.
Radiation: At night, the patient feels severe pain throughout her chest region
Time Relationship: At first, this condition was still developing and was easy to handle. However, it has evolved and has gotten worse.
Duration: It has been two weeks since the patient started experiencing the symptoms.
Association: The symptoms experienced by the patient are similar to those of flu.
Source of Relief: According to the patient, she feels better when resting after doing some light physical exercise.
Source of Aggravation: The symptoms become worse during the night. Again, exposure to allergens such as dust or cold increases the symptom’s severity.
Past History
General State of Health: The patient’s general condition is fair, considering she is suffering from a chronic illness.
Childhood Illnesses: She suffered from smallpox and measles as a child
Adult Illnesses: Hypertension, Anemia, and asthma
Psychiatric Illnesses: She has experienced mild depression in the past
Accidents and Injuries: Never had an accident or injuries
Operations: The patient denies any surgical operations
Hospitalizations: After visiting the hospital, the patient got an admission to the Jackson Hospital for one week to undergo treatment for asthma and hyper ...
SOAP NotePatient Initials RA Pt. Encounter Number .docx
SOAP Note
Patient Initials: RA Pt. Encounter Number: 1
Date: 10/1/20 Age: 23 Sex: female
Allergies: NKA Advanced Directives: none
SUBJECTIVE
CC: “I have been having heavy periods for 4-5 months now. I feel tired and dizzy most days”
HPI: 23-year-old came to the clinic today complaining of heavy menstrual periods happening for the past 4 to 5 months. Accompanying the heavy flow, patient states that she has moderate cramps. Pt describes the pain as stabbing and its 3 out of the 0-10 scale. Patient does not take any medications for the pain. The pain is decreased by applying warm compresses to the lower abdominal area. In addition, patient complains of feeling dizziness and tiredness most of the times.
Current Medications: none
PMH Medication Intolerances: NONE Chronic Illnesses/Major traumas: NONE Screening Hx/Immunizations Hx: Vaccinations up to date, most recent pap smear 12/19 – negative Hospitalizations/Surgeries: None
Family History:Father: Alive, No medical history Mother: Alive, Htn
Social History: Patient is a full-time college student and part time employee at Publix as cashier. Pt lives at home with parents and denies having had a sexual partner for the past year. Patient denies the use of cigars, alcohol, or illegal drugs.
ROS
GeneralDenies recent weight loss, fever, change in appetite or headaches. She denies chills or night sweats. CardiovascularDenies palpitations, chest pain, orthopnea, and claudication. Reports episodes of hypotension.
SkinDenies bruising, skin rash, or discoloration. Denies changes in moles or skin breakdown. RespiratoryDenies shortness of breath, abnormal sputum, cough, or wheezing.
EyesDenies pain, redness, loss of vision, double or blurred vision GastrointestinalDenies abdominal pain, decreased appetite, nausea, or vomiting. Denies food intolerances and changes in stool
EarsDenies ear pain, ear infections, or tinnitus Genitourinary/GynecologicalDenies dysuria, flank pain, and hematuria. Denies abnormal vaginal discharge or itching. Denies STI history. Reports heavy menstrual periods lasting 5 to 6 days, associated with cramping; every 28 days. OBSTETRIC/GYNECOLOGICAL Hx:Menarche: 11 years LMP: 09/15/20 G 0 T 0 P 0 A 0 L 0 Birth Control/Type: NoneMenopause: no Sexually Active: yes STD Hx: None
Nose/Mouth/ThroatDenies nasal pain, congestion, epistaxis, or postnasal drip. Denies pain in mouth, bleeding gums, or dry mouth. Denies pain in throat, hoarseness, difficulty or painful swallowing. MusculoskeletalDenies muscle pain or joint pain. Denies limited range of motion
BreastDenies breast tenderness, discharge, redness, or lumps. NeurologicalDenies headache, dizziness, seizures, or memory loss.
Heme/Lymph/EndoPt denies bruising PsychiatricDenies mood changes, irritability, or changes in concentration. Denies hav.
History taking - For Surgical patients
This PPT is based on taking history from surgical patients for UG - Students. ( Based on History taking methods adopted by S.Das )
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.
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.
Copyright © 2015 by Mosby, an imprint of Elsevier Inc.x-3
Copyright © 2015 by Mosby, an imprint of Elsevier Inc.
x-3
Student Checklist
Ball: Seidel’s Guide to Physical Examination, 8th Edition
Chapter 05: Mental Status
Student Checklist
Adult Examination Checklist
Mark data, when appropriate, to indicate the following:
If normal, * if abnormal, O if absent.
Subjective Data
__Alertness
__Emotional status
__Orientation
__Time
__Place
__Person
__Analogies (similarities)
__Abstract reasoning (fable, proverb)
__Arithmetic calculations
__Writing ability
__Motor skills
__Memory
__Immediate
__Recent
__Remote
__Attention span (short commands)
__Judgment/decision making (hypothetical situation)
__Voice
__Quality
__Pace
__Loudness
__Articulation
__Comprehension
__Coherence (perceptions clearly conveyed)
__Mood and feelings
__Thought processes (logical)
__Perceptual distortions (hallucinations)
Objective Data
Observation
__Alertness
__Grooming
__Body language
__Emotional status
__Attention span
__Coherence
__Voice
__Quality
__Pace
__Loudness
__Articulation
__Comprehension
__Mood and feelings
__Thought processes
__Perceptual distortions
Testing
__Orientation
__Time
__Place
__Person
__Analogies
__Abstract reasoning
__Arithmetic calculations
__Writing ability
__Motor skills
__Memory
__Immediate
__Recent
__Remote
__Attention span
5-2
Student Checklist
Copyright © 2015 by Mosby, an imprint of Elsevier Inc.
Copyright © 2015 by Mosby, an imprint of Elsevier Inc.
Copyright © 2011 by Mosby, Inc., an affiliate of Elsevier Inc.
Detail those data marked as abnormal:
Episodic/Focused SOAP Note Template
Patient Information:
Initials, Age, Sex, Race
S.
CC (chief complaint) a BRIEF statement identifying why the patient is here - in the patient’s own words - for instance "headache", NOT "bad headache for 3 days”.
HPI: This is the symptom analysis section of your note. Thorough documentation in this section is essential for patient care, coding, and billing analysis. Paint a picture of what is wrong with the patient. Use LOCATES Mnemonic to complete your HPI. You need to start EVERY HPI with age, race, and gender (e.g., 34-year-old AA male). You must include the seven attributes of each principal symptom in paragraph form not a list. If the CC was “headache”, the LOCATES for the HPI might look like the following example:
Location: head
Onset: 3 days ago
Character: pounding, pressure around the eyes and temples
Associated signs and symptoms: nausea, vomiting, photophobia, phonophobia
Timing: after being on the computer all day at work
Exacerbating/ relieving factors: light bothers eyes, Aleve makes it tolerable but not completely better
Severity: 7/10 pain scale
Current Medications: include dosage, frequency, length of time used and reason for use; also include OTC or homeopathic products.
Allergies: include medication, food, and environmental allergies separately (a description of what the allergy is ie angioedema, anaphylaxis, etc. This will help determine a true reaction vs intolerance).
PMHx: inc ...
Antenatal care
The document outlines the components and process of antenatal care, which includes screening for high-risk cases, educating mothers on pregnancy and delivery, and ensuring a healthy pregnancy and delivery for both mother and baby. Antenatal care involves taking a medical history, conducting physical and obstetric examinations including measuring fundal height and fetal position, performing lab tests, and providing health education and immunizations. The goal of antenatal care is to monitor for and treat any complications in order to result in a normal pregnancy and delivery of a healthy baby from a healthy mother.
Internal medicine
The document provides an overview and examples of various note formats used in internal medicine, including formats for history and physical exams, progress notes, admission and discharge orders, and specialty notes. It includes mnemonics, equations, and classifications to guide note writing. The document aims to familiarize medical students with the structure and components of different types of notes commonly written in internal medicine.
internal medicine.pdf
The document provides an overview and examples of various note formats used in internal medicine, including formats for history and physical exams, progress notes, admission and discharge orders, and specialty notes. It includes mnemonics, equations, and classifications to guide documentation. Sections cover topics such as cardiology, gastroenterology, pulmonary medicine, and intensive care unit notes.
PEDIATRIC FILLABLE SOAP NOTE TEMPLATE PEDIATRIC FILLABLE SOAP NO.docx
PEDIATRIC FILLABLE SOAP NOTE TEMPLATE
PEDIATRIC FILLABLE SOAP NOTE TEMPLATE
PEDIATRIC FILLABLE SOAP NOTE TEMPLATE
STUDENT NAME:
DATE OF ASSIGNMENT: 05/11/2020
Patient Initials: J.T.
Date of Encounter: 05/06/2020
Sex: Male
Age/DOB/Place of Birth: 12yo, DOB: 05/03/2008, Miami, FL
SUBJECTIVE
Historian: Patient J.T.
Present Concerns/CC: “My throat has been hurting recently”
Reason given by the patient for seeking medical care “in quotes”
Child Profile: (Sexual History (If appropriate); ADLs (age appropriate); Safety Practices; Changes in daycare/school/after-school care;
Sports/physical activity; Developmental Hx)
Patient is sexually inactive, a student at a local middle school, spends his time at home due to the COVID-19 pandemic, otherwise he enjoys playing videogames with his friends all day. The patient spends all of his time at home recently due to the pandemic but would otherwise go out with her family and friends sometimes.
HPI: (must include all components - OLD CARTS)
Patients throat began to hurt 2 days ago. It worsened over the past day, but he states that it is now around the same as yesterday. He states that he can still swallow food and drink, but it hurts when it passes his throat. It is present at all times of day, from when he wakes up, to when he goes to bed. The pain is localized at the back of this throat. It is dull and described as a 3/10. His mother has given him a honey and lime mixture that he states helps for a short while.
Medications: (List with reason for meds)
Patient not currently taking any medication
PMH:
Allergies: Dog hair, cat hair
Medication Intolerances:
None
Chronic Illnesses/Major traumas:
None
Hospitalizations/Surgeries:
None
Immunizations: All vaccines up to date with the exception of the most recent influenza vaccine.
Family History (please identify all immediate family)
Mother: 32 years old, no current health problems
Father: 34 years old, no current health problems
Social History (Education level, occupational history, current living situation/partner/marital status, substance use/abuse, ETOH, tobacco, and marijuana. Safety status)
Middle school student. Does not work. Lives with his parents and 2 brothers, one 6, the other 2 years old. Parents are married. Does not drink alcohol. Does not use recreational drugs, does not use tobacco products, does not smoke, does not vape. The patient states feeling safe at home with his family.
Review of Systems (ROS)
General
Denies fevers, chills, nausea, and vomiting
Cardiovascular
Denies chest pain, pressure, palpitations
Skin
Denies lesions, itching, or redness.
Respiratory
Denies shortness of breath, denies cough, denies difficulty breathing
Eyes
Denies blurred vision, denies visual loss, denies double vision
Gastrointestinal
Denies nausea and vomiting, denies abdominal pain, denies diarrhea, and bloody stools.
Ears
Denies hearing loss, pain, or dra.
Health assessment
The document discusses the components and process of community health assessment by nurses. It begins by defining health assessment as a systematic process of collecting and analyzing data about clients through interaction with them and other providers. The key components of assessment are history taking, physical examination, and review of systems. Specific techniques for physical exams are also outlined. The document then discusses health assessment for different age groups - infants, preschoolers, school-aged children, adults, and elders. It provides details on what to assess for each group, including growth standards. The overall goal of community health assessment is early detection of issues and providing preventative education.
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 ...
Similar to Name Pt. Encounter Number Date Age Sex SUBJ.docx (20)
Comprehensive SOAP TemplateThis template is for a full history.docx
Comprehensive SOAP TemplateThis template is for a full history.docx
Soap notes will be uploaded to Moodle and put through.docx
Soap notes will be uploaded to Moodle and put through.docx
SOAO NotePatient Initials S.MPt. Encounter Number 2 .docx
SOAO NotePatient Initials S.MPt. Encounter Number 2 .docx
Comment by Morgan, Dorothy Tali Do not forget to include a runni
Comment by Morgan, Dorothy Tali Do not forget to include a runni
SOAP NotePatient Initials RA Pt. Encounter Number .docx
SOAP NotePatient Initials RA Pt. Encounter Number .docx
SOAP NOTE SAMPLE FORMAT FOR MRCName LPDateTime 1315.docx
SOAP NOTE SAMPLE FORMAT FOR MRCName LPDateTime 1315.docx
Copyright © 2015 by Mosby, an imprint of Elsevier Inc.x-3
Copyright © 2015 by Mosby, an imprint of Elsevier Inc.x-3
PEDIATRIC FILLABLE SOAP NOTE TEMPLATE PEDIATRIC FILLABLE SOAP NO.docx
PEDIATRIC FILLABLE SOAP NOTE TEMPLATE PEDIATRIC FILLABLE SOAP NO.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
More from pauline234567
Journeys of Paul REL3034.E1Assignment OneWrite about half.docx
Journeys of Paul REL3034.E1
Assignment One
Write about half a page each, single spaced (10 points each). Mention any resources you draw from.
0. Discuss what it meant to be a Roman citizen in Paul’s day. How were citizens better off than the slave class?
0. Summarize Saul’s conversion experience and how he describes himself in various New Testament texts. In what ways do you see this as a dramatic life change?
0. Who was Barnabas? List and detail his appearances in the Book of Acts. Describe his importance in assisting Paul to get acquainted with Christians.
0. Discuss social, political, and religious factors that contributed to the rapid spread of Christianity during the first century.
Paul
ApostleoftheHeatSetFree
‘WheretheSpiritoftheLordis,theretheheartisfree’
(2Corinthians3:17,BasicEnglishVersion)
F.F.Bruce
DIGITALLIBRARY
Copyright©1977F.F.Bruce
Firstpublished1977byPaternoster
Revised(second)Edition1980
ThisDigitalEdition2005
PaternosterisanimprintofAuthenticMedia,
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MiltonKeynes,MK11QR,UK.
and
P.O.Box1047,Waynesboro,
GA,3080-2047,U.S.A.
TherightofF.F.BrucetobeidentifiedastheAuthorofthisWorkhasbeenasserted
inaccordancewithCopyright,DesignsandPatentsAct1988.
Allrightsreserved.Nopartofthispublicationmaybereproduced,storedina
retrievalsystem,ortransmittedinanyformorbyanymeans,electric,mechanical,
photocopying,recordingorotherwise,withoutthepriorpermissionofthepublisher
oralicensepermittingrestrictedcopying.IntheU.K.suchlicensesareissuedbythe
CopyrightLicensingAgency,90TottenhamCourtRoad,LondonW1P9HE.
BritishLibraryCataloguinginPublicationData
aCataloguerecordforthisbookis
availablefromtheBritishLibrary
ISBN1-84227-302-7
TOMYGRAND-DAUGHTERS
HELEN,ANNA,ESTHERANDWINONAMARY
ANDMYGRANDSONS
PETER,FREDERICK,ALANANDPAUL
bearinginmindT.R.Glover’scommentonaRomanEmperor’s
condemnationoftheApostletotheGentiles—thatthedaywas
tocomewhenmenwouldcalltheirdogsNeroandtheirsons
PAUL
Contents
Preface
Abbreviations
Introduction
1.TheRiseofRome
2.TheJewsunderForeignRule
3.“OfNoMeanCity”
4.“ThisManisaRomanCitizen”
5.“AHebrewBornofHebrews”
6.“WhentheTimehadFullyCome”
7.TheBeginningof“TheWay”
8.PersecutoroftheChurch
9.PaulBecomesaChristian
10.PaulandtheJerusalemTradition
11.PaulandtheHistoricalJesus
12.PaulandtheExaltedChrist
13.PaulandtheHellenisticMission
14.ManofVisionandManofAction
15.ConferenceinJerusalem
16.ChurchExtensioninCyprusandAsiaMinor
17.TheGentileProblem
18.“WhattheLawcouldnotdo”
19.FleshandSpirit
20.AntiochtoPhilippi
21.ChristianityinThessalonica
22.PaulandtheAthenians
23.TheChurchofGodatCorinth
24.CorinthianCorrespondence
25.BaptismandtheLord’sSupperinPaulineThought
26.Ephesus:OpenDoorandManyAdversaries
27.PaulandtheLifetoCome
28.FarewelltoMacedoniaandAchaia
29.TheGospelaccordingtoPaul
30.LastVisittoJerusalem
31.CaesareaandtheAppealtoCaesar
32.“AndSoWeCametoRome”
33.PaulandRomanChristianity
34.TheLettertoPhilemon
35.PrincipalitiesandPowers.
JW House FundraiserJourney Through the Enchanted Forest Ga.docx
JW House Fundraiser
Journey Through the Enchanted Forest Gala
Silent Auction
Table Decor
Specialized cocktails for Event
Three Screens will be Placed for Optimum Viewing by all Attendees
New House Announcement
Happy 30th Birthday, JW!
Auction
Isle down Center Allows Fundraising Auctioneer to Engage Audience
Balloon
Drop
S’mores Sponsored by Largest Corporate Donor
Finish the Evening with Dancing & Beverages
Image Sources
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https://www.thegirlcreative.com
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https://t3.rbxcdn.com/ea203ae8bb1787569f5e375cde0a93b2
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https://lhueagleeye.files.wordpress.com/2015/11/crowd_20080505124150.jpg
www.socialtables.com
https://media-cdn.tripadvisor.com/media/photo-s/03/0d/c8/a7/santa-clara-convention.jpg
https://s3.amazonaws.com/assets.winspireme.com/LPP/Buy-it-Now-Logo.png
http://www.tastefultreats.com/media/catalog/product/cache/1/image/9df78eab33525d08d6e5fb8d27136e95/g/o/gourmet-kosher-sweets-gift-basket.png
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http://pngimg.com/uploads/question_mark/question_mark_PNG126.png
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1. INTRODUCTION. Begin by stating what you will discuss and explain why is important.
2. CRITICAL SUMMARY. Summarize the relevant views and the arguments that you believe are important.
Usually in a critical discussion it is not sufficient to merely summarize the author’s view. Your attention should be
focused on the author's development of the view--that is, on his arguments, in the broadest sense of the word.
3. CARE IN CITATIONS. Make sure you accurately state the position of the author and always include page
references for each quotation or attribution to her/him if applicable.
4. CRITICAL EVALUATION FROM A CHRISTIAN PERSPECTIVE. At least half of your paper must be devoted
to a critical evaluation of the views of the author you are discussing from the perspective of the Christian thesis that
a Christian call in business may prop-up the role of the markets.
5. CONSIDER POSSIBLE RESPONSES TO YOUR OBJECTIONS. Whenever you offer an objection to an
author's position, explicitly consider whether the author has said anythin.
JP Morgan Chase The Balance Between Serving Customers and Maxim.docx
JP Morgan Chase: The Balance Between Serving Customers and Maximizing Shareholder Wealth
Penelope Bender
William Woods University
BUS 585: Integrated Studies in Business Administration
Dr. Leathers
Abstract
This paper investigates why JP Morgan Chase and other financial institutions struggle to balance client interests over maximizing wealth.
It is an exploratory study done through literature review.
Often financial institutions, like JP Morgan, put profits ahead of the interests of those they serve.
The paper contributes to better understanding of corporate culture.
This paper investigates why JP Morgan Chase and other financial institutions struggle to balance client interests over maximizing shareholder wealth. This exploratory study is done through a literature review to answer why financial institutions, specifically JP Morgan, often put profits ahead of those they serve. The study will provide evidence of the complex nature of balancing client interests over maximizing shareholder and individual wealth and the need for tighter internal and external oversight. This paper contributes to a better understanding of why corporate culture encourages profit over stakeholders’ interests.
2
Research Question
Why does JP Morgan Chase and other financial institutions struggle to balance client interests over maximizing shareholder wealth?
Employees of JP Morgan Chase and other large banks work in their best interests to increase wealth and succeed by meeting management goals. However, because of the complex nature of large banks, an individual(s), unethical behavior can go unchecked.
3
Problem Statement
JP Morgan Chase competes globally and faces competition from other large banks in the US and abroad.
JP Morgan Chase is part of a complex system of regulation, self-interests, and wealth creation.
The interests of shareholders and investors is sometimes overshadowed by agents working in their own best interests.
Financial markets are a complex web of interests, and because of opportunities for individual profits, regulating individual’s actions without stricter regulations and internal oversight is impossible.
The study is not meant to be a moral or ethical analysis but merely why the complex relationship exists and will continue to exist in capitalist society. This paper contributes to a better understanding of why capitalism or financialism’s (Clarke, 2014) fundamentals encourage wealth creation. Financial markets are a complex web of interests, and because of opportunities for individual profits, regulating individual’s actions without stricter regulations and internal oversight is impossible.
4
Literature Review
The literature review showed a connection between self-interests, regulators, competition, and risk, which all lead to a complex system of conflicting agendas.
5
How Self-Interests Influence Behavior
Ross (1973) explains that all employment relationships are agency relationships and moral hazards are generally .
Interpret a Current Policy of Three CountriesInstructionsAs .docx
The document provides instructions for an assignment analyzing the immigration systems of three countries. It requires:
1) A SWOT analysis of the US immigration system and two other country systems, evaluating strengths, weaknesses, opportunities, and threats.
2) An analysis of immigration benefits for each system to determine the best fit for the student's state.
3) A plan for implementing the chosen immigration program.
The analysis should compare immigration approaches in the US and two other countries. The completed assignment must be 12-15 pages long with a minimum of seven scholarly references using current APA standards.
INTRODUCTIONWhen you think of surveillance, you may picture tw.docx
INTRODUCTION
When you think of surveillance, you may picture two police officers camped out in an unmarked car, watching the comings and goings at a suspect’s apartment building. Or you may imagine an investigator trailing a car on the highway or tapping a suspect’s phone to listen in on potentially incriminating conversations. Surveillance is all these activities, but in the 21st century, it is also much more.
Consider video surveillance of local businesses, streets, and highways; cell phone data; and the reams and reams of digital information gathered on everyday activities—from social media and computer use to credit card transactions.
This week, you analyze concerns related to this new era of surveillance, such as privacy and legal requirements.
LEARNING OBJECTIVES
Students will:
Analyze issues related to privacy and surveillance
Describe surveillance
Differentiate between legal and illegal surveillance
Analyze legal requirements for conducting surveillance
PRIVACY VERSUS PUBLIC SAFETY
The average citizen today may feel as though they are constantly being watched and their actions recorded. And perhaps rightly so. After all, social media sites market personalized products based on how you use the Internet, cell phones pinpoint your location, and fitness trackers transmit your health and fitness activities to the cloud. This sense of being “spied on,” however, does not negate the important use of surveillance techniques in solving and preventing crime.
For this Discussion, you analyze how to balance two sometimes opposing sides in surveillance work: the expectation of privacy and the goal of public safety.
RESOURCES
Be sure to review the Learning Resources before completing this activity.
YOU WILL FIND THE READING FOR THIS ASSIGNMENT IN THE ATTACHED READING MATERIALS PLEASE GO THERE AND READ BEFORE TRYING TO COMPLETE THIS ASSIGNMENT SO YOU WILL UNDERSTAND WHAT IS NEEDED TO COMPLETE THE WORK….
Post a response to the following:
When conducting surveillance, explain how to balance an expectation of citizen privacy with legitimate investigative procedure that has public safety as its goal.
Explain whether citizens should differentiate between government intrusion and private companies who use citizens’ online data to surveil their movements and activity.
.
Interviews and Eyewitness Identifications AP PhotoMat.docx
Interviews and
Eyewitness
Identifications
AP Photo/Matthew Apgar
OBJECTIVES
After reading this chapter you will be able to:
• Identify the evidence collected
by investigators in the BP
gas station robbery and
discuss its role in the
identification and apprehension
of the perpetrator.
• Discuss the advantages and
disadvantages of using facial
identification software and
forensic sketches to create
composite pictures of
suspects.
• Identify and discuss the
rationale of the recommended
lineup procedures.
• Discuss the research that
has been conducted on the
accuracy of hypnotically elicited
testimony. • Identify the difference between
primary and secondary
witnesses and give an example
of each.
• Discuss the value of eyewitness
identifications in establishing
proof. • Compare and contrast the
cognitive interviewing approach
with standard police interviews.
• Identify and discuss the
methods of eyewitness
identifications.
• Identify the three phases of
human memory and discuss
how factors at each phase
may affect the retrieval of
information from witnesses.
• Discuss the contributions
of cognitive interviewing in
enhancing memory recall.
From the CASE FILE
BP Gas Station Robbery
The introduction to this chapter consists of a police
report (edited for length) of the investigation of an
armed robbery of a British Petroleum (BP) gas station
that occurred on August 22, 2011, in Germantown,
Wisconsin (a suburb of Milwaukee). The report serves
as an example of a criminal investigation case report
and also highlights issues discussed in this chapter,
such as the value of eyewitness identification. Issues
discussed in other chapters, including the important
role of patrol officers in investigations, crime scene
photographs, investigation of robbery and auto theft,
and the value of DNA, are also present in this report.
Incident Report Number: 11-014277,
Report of Officer Toni Olson
On Monday, August 22, 2011, I, Officer Olson, was
assigned to investigate and respond to a robbery, which
had just occurred at the County Line BP, located at 21962
County Line Road. Officers were advised that the c I erk at
the BP gas station had called the non-emergency number
reporting that a younger wh ite male came into the store and
hit him over the head with an unknown object before taking
money out of his cash drawer and leaving in a red SUV or
truck, northbound on Bell Road. A possible registration
of 583RIB was given out for the suspect vehicle. I, along
with Lt. Huesemann, Officer Brian Ball, and Officer Daniel
Moschea of the Germantown Police Department responded.
Upon arriving on scene, officers were advised that witnesses
reported the suspect veh icle leaving the scene of the
robbery northbound on Bell Road into a subdivision. The
witnesses also stated that they had not seen the suspect
vehicle leave the subdivision, which only has two ways to get
in and.
Interview Presentation QuestionsTo prepare · I.docx
Interview Presentation: Questions
To prepare:
· Identify an interview subject with a different cultural background than you.
· Ask your interview subject the questions below. Be sure to record the interview and/or take good notes.
During the interview, ask the individual the following interview questions:
· Have you ever lived or visited outside of the United States? If so, where? Describe the experience.
· What do you identify as your culture?
· What are the most important values and beliefs of your family and community?
· What are the important events, traditions, celebrations, and practices in your family or community?
· How does your family or community define gender roles?
· How do you identify your:
· Race
· Ethnicity
· National origin
· Color
· Sex
· Sexual orientation
· Gender identity or expression
· Age
· Marital status
· Political belief
· Religion
· Immigration status
· Disability status
· How well do you fit within your family or community based on these other identities you hold?
· How do you think others outside your community view your culture?
· Have you experienced prejudice or discrimination? Please describe.
Social Media and Ethical Considerations
Walden’s MSW Social Media Policy
A student’s presence on and use of social media reflects on the MSW program and the social
work profession; therefore, behavior on social media will be held to the same professional
standards and student code of conduct expectations. Social Work professionals, including
students, are expected to adhere to the NASW Code of Ethics related to virtual communications.
Students should use social work values and principles, as well as specific agency policy, to guide
their social media interactions.
Students need to consider the ethical consequences of their own social media use, as well as use
of social media in practice. Be aware of and follow agency policies regarding the use of social
media. Before using social media communication tools on behalf of a field agency, students
must seek agency approval of any messages or posts.
Walden MSW students are expected to adhere to the ethical standards outlined in the NASW
Code of Ethics. Common ethical issues that social workers need to understand and manage when
utilizing social media include, but are not limited to, privacy and confidentiality (Section 1.07),
conflicts of interest and dual relationships (Section 1.06), and informed consent (Section 1.03).
There is significant risk of unintentionally sharing protected information when using social
media. Be cautious when posting information about an agency. Never post confidential or
private information about clients or colleagues, even using pseudonyms.
Students need to remain aware of professional boundaries even when participating in social
media in their personal time. Managing “friend” requests and maintaining privacy settings is
critical regardless of whether a student uses social me.
INT 220 Business Brief Template Course Project.docx
INT 220 Business Brief Template
Course Project
Section One: Drivers for Global Entry
Going global would afford the company many benefits including increased sales and revenues. Japan is a developed market and thus the purchasing power of the consumers is high, which implies that many consumers will be able to purchase our products. Expanding to Japan will enable increased profits that can be reinvested in research and development of new technology and innovation that will create a competitive advantage for both domestic and international market. In addition, entering the foreign market will help the business to tap into new market segment. According to International Data Corporation (IDC), Apple was the largest smartphone brand in 2020 in Japan with a 47.3 percent market share (Sudarshan, 2021). The data shows that Japan would be an ideal market for quality phone cell cases due to high purchase of smartphones. Therefore, the company will benefit from increased sales and profits.
Section Two: Market Profile
Cultural Profile
CategoryUnited StatesJapan
Commonly Spoken Languages
English
Japanese
Commonly Practiced Religions
Christianity
Shinto
Power Distance Index (PDI)
40
54
Individualism Versus Collectivism (IDV)
91
46
Masculinity Versus Femininity (MAS)
95
62
Uncertainty Avoidance Index (UAI)
92
46
Long-Term Orientation Versus Short-Term Normative Orientation (LTO)
88
26
Indulgence Versus Restraint (IVR)
42
68
Political and Economic Profile
CategoryUnited StatesJapan
Political System
Representative democracy
Constitutional monarchy
Current Leaders
Joseph Biden president
Fumio Kishida prime minister
Economic Classification
Developed
Developed
Economic Blocs Impacting Trade
World trade organization
World trade organization
Gross Domestic Product
23 trillion USD
4.9 trillion USD
Purchasing Power Parity
22,996.08
100.412
Gross Domestic Product Per Capita
69,287.54 USD
39,285.16 USD
Human Development Index
Very high 0.921
0.919
Human Poverty Index
$26,246 for a family of four
Poverty headcount ratio at $5.50 a day
In terms of economic development, both countries have developed economy, thus making them ideal for business. Consumers have high purchasing power which means that they are able to purchase new products. US has a higher GPD compared to Japan, however, this can be attributed to the size and population of U.S. compared to that of Japan. Furthermore, both countries are members of World Trade Organization, which means that their trade operations with other nations are regulated and subject to WTO regulations. The culture in Japan is hugely different then the culture in America. Americans are self-motivated while the Japanese culture embraces more of a group mentality and looks for approval from their superiors before making big decision. Both cultures work long hours and take very little breaks. For the most part Japanese culture is more formal in the work place then in the U.S.
Section Three: Market Consideratio.
Instructor Name Point Value 30Student NameCATEGORY .docx
Instructor Name: Point Value: 30
Student Name:
CATEGORY Excellent (12–11 points) Good (10–9 points) Fair (8–7 points) Poor (6–1 points) Did Not Complete (0 points) # of points
Content Quality
40% of total Discussion
grade
Student participated in the
Discussion about the presented
topic with detailed, relevant,
supported initial posts and
responses. Student enhanced
points with examples and
questions that helped further
discussion. Discussion is well
organized, uses scholarly tone,
follows APA style, uses original
writing and proper paraphrasing,
contains very few or no writing
and/or spelling errors, and is fully
consistent with graduate-level
writing style. Discussion contains
multiple, appropriate and
exemplary sources
expected/required for the
assignment.
Student participated in the
Discussion about the presented
topic with detailed, relevant,
supported initial posts and
responses. Discussion is mostly
consistent with graduate level
writing style. Discussion may have
some small or infrequent
organization, scholarly tone, or
APA style issues, and/or may
contain a few writing and spelling
errors, and/or somewhat less than
the expected number of or type of
sources.
Student participated in the
Discussion about the presented
topic with adequate content but
the content lacked either detail,
relevancy, or support. Discussion
is somewhat below graduate level
writing style, with multiple smaller
or a few major problems.
Discussion may be lacking in
organization, scholarly tone, APA
style, and/or contain many writing
and/or spelling errors, or shows
moderate reliance on quoting vs.
original writing and paraphrasing.
Discussion may contain inferior
resources (number or quality).
Content of student's post and
responses was not clear, relevant,
or supported. Discussion is well
below graduate level writing style
expectations for organization,
scholarly tone, APA style, and
writing, or relies excessively on
quoting. Discussion may contain
few or no quality resources.
Student did not submit a post or
response.
CATEGORY Excellent (12–11 points) Good (10–9 points) Fair (8–7 points) Poor (6–1 points) Did Not Complete (0 points) # of points
Engagement
40% of total Discussion
grade
Student participated actively as
evidenced by strong reflective
thought in both the initial post and
in responses to classmates' posts.
Student response participation
exceeded the stated minimum
requirements.
Student participated actively as
evidenced by strong reflective
thought in both the initial post and
in responses to classmates'
posts.Student responses
contributed to classmates'
experience.
Student participated somewhat
actively as evidenced by posts
and responses that were adequate
but lacking strong reflective
thought.
Student did not participate actively
as evidenced by little reflective
thought in i.
InstructionsThere are two high-level types of distribution cha.docx
Instructions
There are two high-level types of distribution channels, direct and indirect. In the direct distribution channel, goods are moved directly from the Producer to the Consumer. In the indirect distribution channel, the producer will meet consumer demand through third -party wholesalers and/or retailers. Direct channels produce short supply chains, indirect channels produce long chains.
Research and report on two large producers, Costco and Apple, and describe in detail which distribution approach each company uses -- direct, indirect, or mixed – for at least two products in each company.
Your APA paper should be at least 1,000 words in length.
.
InstructionsNOTE If you have already reviewed this presentation.docx
Instructions
NOTE: If you have already reviewed this presentation in a different class please enter class number and instructor’s name in the submission text box below.
____________________________________________________________________
If you have not reviewed this presentation in a previous class, please proceed.
Please review the curated presentations below. These presentations will prepare you for writing deliverables that meet the expectations of this course. We want you to be successful in all your courses so please refer back to this tool often. This presentation is located in the library and the Student Center. To view an presentation, please click on the button below. Be sure to review all five presentations for this week!
Presentation Four: The Research Process & Choosing a Topic
Presentation Five: Types of Sources
Presentation Six: Search Strategies & Techniques
Presentation Seven: Evaluating Information
Presentation Eight: Ready to Shine!
When you have finished reviewing all five presentations, please copy and paste the following statement into the submission box below:
STATEMENT: I HAVE REVIEWED WEEK TWO INFORMATIONAL PRESENTATION. I UNDERSTAND THIS PRESENTATION IS ALSO LOCATED IN THE LIBRARY AND STUDENT CENTER FOR FUTURE REFERENCE.
.
InstructionsA SWOT analysis is used as a strategic planning tech.docx
Instructions
A SWOT analysis is used as a strategic planning technique by businesses and/or individuals to identify
strengths, weaknesses, opportunities, and threats to a planned project. It identifies conditions that are favorable or unfavorable to achieving the goal of the project by grouping them into categories:
Strengths and Weakness are frequently internally related, while Opportunities and Threats commonly focus on environmental factors.
·
Strengths: characteristics of the projected solution that give it an advantage over others.
·
Weaknesses: characteristics that place the projected solution at a disadvantage relative to others.
·
Opportunities: elements in the environment that the projected solution could exploit to its advantage.
·
Threats: elements in the environment that could cause trouble for the projected solution.
Instructions:
1. Download the worksheet attached to this assignment below.
2. Based on what you found in your annotated bibliography, identify a plan that you could propose/implement that addresses your health issue.
3. Be specific and list the objectives and the interventions needed on the worksheet.
4. Then list 3 each of the strengths, weaknesses, opportunities, and threats to your proposed solution.
5. Finally, list ways you can capitalize on the strengths and opportunities, and ways you can mitigate the weaknesses and threats, when thinking about your plan.
Complete this SWOT Analysis and upload it to this assignment dropbox. This assignment is due by Sunday at 11:59 pm CT.
INTRODUCTION TO DATA MINING
INTRODUCTION TO DATA MINING
SECOND EDITION
PANG-NING TAN
Michigan State Universit
MICHAEL STEINBACH
University of Minnesota
ANUJ KARPATNE
University of Minnesota
VIPIN KUMAR
University of Minnesota
330 Hudson Street, NY NY 10013
Director, Portfolio Management: Engineering, Computer Science & Global
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Maura Zaldivar-Garcia
Inventory Manager: Ann Lam
Product Marketing Manager: Yvonne Vannatta
Field Marketing Manager: Demetrius Hall
Marketing Assistant: Jon Bryant
Cover Designer: Joyce Wells, jWellsDesign
Full-Service Project Management: Chandrasekar Subramanian, SPi Global
Copyright ©2019 Pearson Education, Inc. All rights reserved. Manufactured in
the United States of America. This publication is protected by Copyright, and
permission should be obtained from the publisher prior to any prohibited
reproduction, storage in a retrieval system, or transmission in any form or by
any means, electronic, mechanical, photocopying, recording, or like.
InstructionsRead two of your colleagues’ postings from the Di.docx
Instructions:
Read two of your colleagues’ postings from the Discussion question.
Respond with a comment that asks for clarification, provides support for, or contributes additional information to two of your colleagues.
Timia Brown (
She/Her)
In healthcare, whether long-term or acute care, interdisciplinary communication is necessary to provide patient-centered care. The two scenarios provided both effective and ineffective communication.
Scenario 1
Assuming the leader for the interdisciplinary rounds was the case manager, she introduced the nursing student, who was not paying attention. The case manager did not present other team members, so the student was left guessing. The pharmacist and the physical therapist were laughing and talking during the discussion. There was no engagement; the MD was on her phone, and everyone was preoccupied. Each team member individually knew the patient and his shortcomings, yet there was no preparation for the actual engagement with each other. Each team member projected issues onto the next member, using terms such as "somebody" or "someone" needed to do this. There was no responsibility for care. The team spoke unprofessionally to each other, using words like "yep" and "umm." In the end, the case manager assigned responsibility; however, the disciplines accepted the responsibility grudgingly. The team's disrespect for each other was portrayed to the student, who was disengaged throughout the meeting. The patient was not ready to be discharged from the sound of this scenario. The patient's pain was not controlled, nor was his anxiety; no equipment had been ordered for discharge. The patient's safety was not a priority in this meeting, which could lead to readmission or fall risk at home.
In scenario two, the team all appeared happy to be there, with smiling faces and excellent eye contact. The leader engaged the nursing student immediately by having the team introduce themself. The team was much more prepared and engaged. Each member respected the other's role in providing care and a safe, patient-centered discharge. The team took responsibility for what was needed from each of them now and at the time of release. The communication was more two-way communication. They did a recap of what was discussed, and everyone willingly took part in making sure the patient went home safely and confidently.
Effective communication between interdisciplinary teams must be present to provide the care needed for each patient. It starts with respecting each other's role in the patient's care and remembering the patient is the priority. The
Journal of Communication in Healthcare stated the leading cause of all sentinel events from 1995 to 2004 was ineffective communication. (2019, Altabba) Therefore effective communication could decrease the number of incidents, and lead to proper care.
References
Altabbaa G, Kaba A, Beran TN. Moving from structure.
InstructionsRespond to your colleagues. Respond with a comment .docx
Instructions:
Respond to your colleagues. Respond with a comment that asks for clarification, supports, or contributes additional information to two or more of your colleagues.
Reynaldo Guerra
As influencers in our society, that bring about social change in healthcare as all those we contact, the type of agent I would align with is a Purposeful Participant. Where "School or work are the primary motivations for involvement in positive social change." (
What kind of social change agent are you? n.d.) are what defines greatly the type of agent I am. Due to my desire to expand my education and grow, I have been allowed to not just see but know that I can contribute to various aspects of healthcare. At the hospital I currently am employed, many principles are introduced to us and help us with making a difference for our patients as all professionals alike by the way we interact and the relationship we create with everyone. Even if driven by these two motivators, they have opened my eyes and expanded my limitations in the change we can bring about.
This eye-opening experience has changed my perspective on how I can make a social change with all those around me. I now feel that a cascade effect comes from my changes as little as it might seem, it gets passed down and impact larger changes in the long run. How I speak with my patients and show the advocate I am for them in addressing their healthcare issues with importance, to the trust and relationship I have created with the primary care providers, goes to show these small social changes can in the end bring a great change for all. This has shown me that social change has a larger purpose in the end and even as small of a change we bring about, if we all come together and do the same, the results would be even more significant than what we perceived as a small change in the beginning. From our professional interactions with one another to our desire to help and better our care with all patients alike, these changes have a great purpose and impact on our future as everyone else.
Apart from that, social change has influenced my education by motivating me to seek ways to make a difference in a community project presented by my university. It has ignited a flame in me, so to speak, and piqued my interest in seeing what my university has to offer in making a social change. Whether this is by being part of projects, joining a committee, or being part of future alumni programs to help others. Also, being able to refine my nursing practice in our community as in the hospital has been a change for me. This, in turn, will be put forth in the interactions and relationships I create with my patients, colleagues, peers, and others I come in contact with, hopefully, bringing a social change in the end. This is what the principles of social change will bring about for me.
References
Walden University. (n.d.).
What kind of social change agent are you? Lin.
InstructionsProcurement Outsourcing (PO) StrategiesPO strat.docx
Instructions
Procurement Outsourcing (PO) Strategies:
PO strategies at the highest level involve either materials or traditional business processes such as HR, IT, Finance, Accounting, Travel/Entertainment services, Marketing/Print/Advertising, or Customer Relationship Management (CRM). Your task here is to choose a public business organization and report on what direct materials are being outsourced. Direct materials are categorized as strategic (high-impact), bottleneck items (low-profit impact and high-supply risk), leverage items (high-profit items and low-supply risk), or non-critical (low-profit impact and low-supply risk). Describe the outsource process in detail, who provided the outsourced services, and what direct materials were involved.
You are to prepare a PowerPoint presentation, with a minimum of twelve (12) slides, to include inline citations, a cover slide, and a slide of references. Your citations and references should be APA-compliant.
Level of writing: Exemplary
.
InstructionsPart Four of Applied Final Project,Playing with Ge.docx
Instructions
Part Four of Applied Final Project,Playing with Gender: Understanding Our Gendered Selves:
"Understanding My Playing-with-Gender Act" (20% of course grade; due end of Week 7) Five (5) pages (1200-1500 words)
All parts of this project should be formatted in APA style (follow for both essay and citation styles):https://libguides.umgc.edu/c.php?g=1003870
Purpose: Act Analysis
In this part of the assignment, you will perform, describe, and analyze your act. After you perform your act, compose a 5-page (1200-1500 words) task specifying your experiences. The first section (one-third to one-half of your paper) should describe your act and your responses to it, and the second section should analyze your act in terms of the scholarship on gender:
Section One (minimum 500 words):
1. Describe your act:
2. What did you do?
3. Where did you do it?
4. How did you prepare for it?
5. What responses did you get while performing your act?
6. How did you feel while performing your act?
7. What would you do differently if you had to perform this same act again? Would you perform the act in the same location and at same time? Would you change your appearance during the act? Would you do anything else differently?
8. Please refer directly to the required reading on Participant Observation (Mack et al., 2005) in this section of the paper (Mack et al., 2005) (
PLEASE see attached for document):
Mack et al. (2005). "Module Two: Participant Observation," from
Qualitative Research Methods: A Data Collector's Field Guide, Family Health International. Read Module 2, pages 13-27. Retrieved from
https://www.fhi360.org/sites/default/files/media/documents/Qualitative%20Research%20Methods%20-%20A%20Data%20Collector's%20Field%20Guide.pdf
Section Two: (minimum 700 words):
(Please see attached for document listing the sources)
Referring directly to at least three academic sources for support (these may be pulled from the sources you identified and discussed in your Annotated Bibliography for Part 3
and/or the readings for this class), consider the potential impact of your act. Here are some questions to consider (you do not have to answer all of these questions; they are provided to help you to think about ways your act may have impact on society):
· Can you explain the range of reactions to your act? Did those reactions reflect any of the sociological scholarship found in the course readings or in your research? Did any of the reactions challenge that research?
· How do you think class, race, age, and sexuality came into play during the conception and performance of the act?
· Was performing this act an act of feminism? Why? and, if so, what type(s) of feminism?
· Was your act an act of activism? That is, could it help to create social change? If so, how?
Please see attached for Project 1, 2 & 3 for information and assistance.
Qualitative
Research
Methods:
A DATA CO L L E.
InstructionsClients come to MFTs because they want to change, .docx
Instructions
Clients come to MFTs because they want to change, whether the change is in cognitions, structure, insight, or something else. Therefore, it is important for you to understanding why, when, and how people change. This week, you will continue the exploration of core concepts related to systems theory and its application to MFT field concepts. You will review several concepts associated with change including homeostasis, first-order change, second-order change, continuous change, and discontinuous change.
Complete the provided worksheet template located in this week’s resources. Note: You will use the worksheet you complete this week as part of your work in Week 4.
For each item, be sure to address the following:
· Record a direct quotation that defines the concept or describes the assumption.
· Paraphrase the definition or description by explaining the information in your own words. As you are paraphrasing, keep in mind that concepts often involve several interrelated ideas. When you are paraphrasing, be sure to not oversimplify the concept.
· Provide an original example (not one you read about in the course resources) of the concept or assumption.
· Explain how your example reflects the definition. Refer to your paraphrased definition in order to compare the example to the concept.
Should you have questions or need clarification on any items, please contact your professor to discuss it.
Length: 1-2 pages (completed template). Additional resources/reference page is not required.
Your cheat sheet should demonstrate thoughtful consideration of the ideas and concepts presented in the course by providing new thoughts and insights relating directly to this topic. Be sure to adhere to Northcentral University's Academic Integrity Policy.
Upload your document, and then click the
Submit to Dropbox button.
Building Blocks to Conceptualizing Family: A Family System’s Perspective Valerie Q. Glass, PhD, LMFT
Background of Systemic Thinking
Systemic thinking, for some, means trying on a new and unique lens when considering “presenting problems” that arise in therapeutic settings. Most mental and emotional health backgrounds study individual cognitive and emotional processes, systemic thinking means a shift in looking at one person to looking at a whole system. Keeney (1983) calls this change in professional theory an epistemological shift. Epistemology, most basically, is the way one understands what is in front of them, and the root with which decisions are made. Helping fields all develop from different epistemologies. Psychiatry views medicine and biology as their epistemological construct of how or why people act the way they do. Much of the epistemological focus of social work fields embraces the necessity or connecting to resources and social support as a catalyst for change. Psychology explores the make-up of the individual’s mind and develops steps for change. Family systems, and.
INST560, Internet of Things (IoT)UNIVERSITY OF NORTH AMERICA.docx
INST560, Internet of Things (IoT)
UNIVERSITY OF NORTH AMERICA
Lecture 3: Fall 2022
Professor Aliakbar Jalali
[email protected]
1
Internet of Things Enabling Technologies
/59
UoNA-ST560-FALL-2022, Internet of Things (IoT)
Overview
Introduction
Evolution of the Technology
Some significant statistics
IoT Technology
Risks of IoT Technologies
Use Cases of IoT Technology!
What are IoT Enabling Technology
Conclusion
References
2
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UoNA-ST560-FALL-2022, Internet of Things (IoT)
Introduction
Because of technological changes taking place in the world, IoT is gradually taking over all the fields, and the future of the IoT applications are increasing day by day.
Technological advances are fueling the growth of IoT.
Technology improved communications and network, new sensors of various kinds; cheaper, denser, more reliable, and power efficient storage both in the cloud and locally are converging to enable new types of IoT based products that were not possible a few years ago.
IoT technology will further develop to make our day-to-day operations much easier and more remotely controlled in the days to come.
3
/59
UoNA-ST560-FALL-2022, Internet of Things (IoT)
Introduction
Businesses need to constantly explore IoT applications within their domain to stay ahead in competitiveness and implementation.
The competition will primarily define in the coming decade as how companies take advantage of innovative technology.
However, it is the dominant technology that determines the future of many businesses attached to the future of the internet of things (IoT).
4
/59
UoNA-ST560-FALL-2022, Internet of Things (IoT)
Introduction
The emerging trends in IoT are majorly driven by technologies like artificial intelligence, blockchain, 5G and edge computing.
We need to know more in detail about the elements that make up broad spectrum of technologies, we know as the Internet of Things.
Technological advances lies in the business value of IoT applications like smart wearables, smart homes and buildings, smart cities, autonomous cars, smart factories, location trackers, wireless sensors and much more.
5
/59
UoNA-ST560-FALL-2022, Internet of Things (IoT)
Introduction: Technology is changing the world!
Technology is changing the world.
It is changing the way we communicate, shop, learn, travel, play and of course the way we work.
http://www.telegraph.co.uk/technology/2017/05/06/internet-things-could-really-change-way-live/
6
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UoNA-ST560-FALL-2022, Internet of Things (IoT)
6
Introduction: Technology is changing the world!
7
Global gigabit subscriptions are expected to jump to 50 million in 2022, more than doubling from 24 million at the end of 2020, according to a new report from analyst firm Omdia.
High Speed Internet!
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UoNA-ST560-FALL-2022, Internet of Things (IoT)
Introduction: Social Media is Changing societies!
8
Are you on social media a lot? When is the last time you checked Twitter, Facebook, or Instagram? Last n.
Insert Prename, Surname of all studentsWinter Term 202223Theo.docx
Insert Prename, Surname of all students
Winter Term 2022/23
Theory Factsheet: Insert name of theory
Level of analysis
Insert levels of analysis, e.g., organisation, individual, social
Dependent construct(s)
Please insert the dependent construct(s) of the theory
Independent construct(s)
Please insert the independent construct(s) of the theory
Short description of the theory
Please describe the theory in full sentences.
Cause-Effect Model
Please insert a visual diagram of the cause-effect relationships or factor model of the theory (if available).
Applications of the theory
Please describe for which purposes / in which fields the theory has been applied.
Which relevance does the theory have for digitalization in organizations?
Criticism
Describe alternative views, potential critique, and open discussion on the theory.
References
Insert sources and references used in this factsheet in APA 7th style.
Students will write a 2-3 pages essay analyzing one of the topics addressed during the semester under the section of Contemporary Issues: Human Rights. The student will be free to choose any of the topics discussed during class as well as his/her opinion about it.
1. Choose a topic (death penalty, assisted suicide, abortion, death by euthanasia, bioethics… etc.)
2. First page: description of the problem (is is here Fl, or national or worlwide, statistics, etc)
Second page: YOUR ETHICAL POSITION ABOUT IT (why is this an ethical issue, where your argument os coming from, etc)
3. REFERENCES (could be ppt, movie, article, web, book)
The writing will be evaluated for clarity and proper handling of terms, phrases, and concepts addressed up to this date. APA or MLA style will be required
https://owl.english.purdue.edu/owl/section/2/10/.
Reading listWinter semester 2022/23
Version 24.09.2022
Reading
Package
No.
Theories Papers
Information Systems Foundational Theories
Structuration Theory Orlikowski, W.J. (1992). The Duality of Technology: Rethinking the Concept of Technology in Organizations. Organization Science, 3 (3), 398-
427.
Structuration Theory Orlikowski, W.J. and Robey, D. (1991). Information Technology and the Structuring of Organizations. Information Systems Research, 2 (2),
143-169.
Structuration Theory Walsham, G. and Han, C.K. (1991) Structuration theory and information systems research. Journal of Applied Systems Analysis 17: 77-85.
Institutional Theory Barley, S.R and Tolbert, P.S. (1997). Institutionalization and structuration: studying the links between action and institution. Organization
Studies 18 (1): 93-118.
Institutional Theory Orlikowski, W. J., & Barley, S. R. (2001). Technology and institutions: What can research on information technology and research on
organizations learn from each other? MIS Quarterly, 25(2), 145.
Design Science Hevner, A. R., March, S. T., Park, J., & Ram, S. (2004). Design science in information systems research. MIS Quarterly, 28 (1), 75.
Informative SpeechCourse COM103 Public SpeakingCriteria.docx
Informative Speech
Course: COM103 Public Speaking
Criteria Level 4 Level 3 Level 2 Level 1 Criterion Score
Introduction / 10
Material / 8
Transitions / 10
10 points
Introduction
contained a
strong
attention
getter,
introduction of
the topic,
credibility
statement, and
previewed the
speech.
7 points
Introduction
contained 3 of
the following:
a strong
attention
getter,
introduction of
the topic,
credibility
statement, and
previewed the
speech.
4 points
Introduction
contained 2 of
the following:
a strong
attention
getter,
introduction of
the topic,
credibility
statement, and
previewed the
speech.
0 points
Introduction
contained 1 of
the following:
a strong
attention
getter,
introduction of
the topic,
credibility
statement, and
previewed the
speech.
8 points
Material was
clear AND
well organized
5.6 points
Material was
either clear
OR well
organized
3.2 points
NA
0 points
Material was
neither clear
and well
organized
10 points
Transitions
were clear and
used after the
intro, between
each main idea
and before the
conclusion
7 points
Transitions
were clear, but
were not used
in all areas:
after the intro,
between each
main idea and
before the
conclusion
4 points
Transitions
used after the
intro, between
each main idea
and before the
conclusion,
but were not
effective
0 points
Transitions
were not used.
Rubric Assessment - COM103 Public Speaking - National University https://nationalu.brightspace.com/d2l/lms/competencies/rubric/rubrics_a...
1 of 4 12/6/22, 5:38 PM
Criteria Level 4 Level 3 Level 2 Level 1 Criterion Score
Conclusion / 8
Time limit / 8
Preparation
outline
uploaded
/ 8
8 points
The
conclusion
contained a
strong closing
AND the
speaker
signaled the
end of the
speech
5.6 points
The
conclusion
contained a
strong closing
OR the
speaker
signaled the
end of the
speech
3.2 points
The speaker
needs
improvement
signalling the
end of the
speech and a
stronger
closing.
0 points
The
conclusion
neither
contained a
strong closing
and the
speaker did
not signal the
end of the
speech
8 points
The length of
the speech
was between
5 and 6
minutes
5.6 points
NA
3.2 points
The length of
the speech
was shorter
than 5 minutes
or longer than
6 minutes
0 points
NA
8 points
The
preparation
outline was
uploaded with
the speech
5.6 points
The
preparation
outline was
uploaded after
delivering the
speech
3.2 points
The
preparation
outline was
not in a
preparation
outline format
0 points
The
preparation
outline was
not uploaded.
Rubric Assessment - COM103 Public Speaking - National University https://nationalu.brightspace.com/d2l/lms/competencies/rubric/rubrics_a...
2 of 4 12/6/22, 5:38 PM
Criteria Level 4 Level 3 Level 2 Level 1 Criterion Score
Eye Contact / 10
Delivery / 10
Non verbals / 10
Overall
preparation
/ 8
10 points
The speaker
had strong eye
contac.
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- 2. Chronic Illnesses/Major traumas Hospitalizations/Surgeries “Have you ever been told that you have diabetes, HTN, peptic ulcer disease, asthma, lung disease, heart disease, cancer, TB, thyroid problems, kidney problems, or psychiatric diagnosis?” Family History Does your mother, father, or siblings have any medical or psychiatric illnesses? Is anyone diagnosed with: lung disease, heart disease, HTN, cancer, TB, DM, or kidney disease? Social History Education level, occupational history, current living situation/partner/marital status, substance use/abuse, ETOH, tobacco, and marijuana. Safety status ROS General Weight change, fatigue, fever, chills, night sweats,
- 3. and energy level Cardiovascular Chest pain, palpitations, PND, orthopnea, and edema Skin Delayed healing, rashes, bruising, bleeding or skin discolorations, and any changes in lesions or moles Respiratory Cough, wheezing, hemoptysis, dyspnea, pneumonia hx, and TB Eyes Corrective lenses, blurring, and visual changes of any kind Gastrointestinal Abdominal pain, N/V/D, constipation, hepatitis,
- 4. hemorrhoids, eating disorders, ulcers, and black, tarry stools Ears Ear pain, hearing loss, ringing in ears, and discharge Genitourinary/Gynecological Urgency, frequency burning, change in color of urine. Contraception, sexual activity, STDs Female: last pap, breast, mammo, menstrual complaints, vaginal discharge, pregnancy hx Male: prostate, PSA, urinary complaints Nose/Mouth/Throat Sinus problems, dysphagia, nose bleeds or discharge, dental disease, hoarseness, and throat pain Musculoskeletal
- 5. Back pain, joint swelling, stiffness or pain, fracture hx, and osteoporosis Breast SBE, lumps, bumps, or changes Neurological Syncope, seizures, transient paralysis, weakness, paresthesias, and black-out spells Heme/Lymph/Endo HIV status, bruising, blood transfusion hx, night sweats, swollen glands, increase thirst, increase hunger, and cold or heat intolerance Psychiatric Depression, anxiety, sleeping difficulties, suicidal ideation/attempts, and previous dx OBJECTIVE Weight BMI Temp BP Height Pulse Resp General Appearance Healthy-appearing adult female in no acute distress. Alert and oriented; answers questions appropriately.
- 6. Slightly somber affect at first and then brighter later. Skin Skin is brown, warm, dry, clean, and intact. No rashes or lesions noted. HEENT Head is normocephalic, atraumatic, and without lesions; hair evenly distributed. Eyes: PERRLA. EOMs intact. No conjunctival or scleral injection. Ears: Canals patent. Bilateral TMs pearly gray with positive light reflex; landmarks easily visualized. Nose: Nasal mucosa pink; normal turbinates. No septal deviation. Neck: Supple. Full ROM; no cervical lymphadenopathy; no occipital nodes. No thyromegaly or nodules. Oral mucosa, pink and moist. Pharynx is nonerythematous and without exudate. Teeth are in good repair. Cardiovascular S1, S2 with regular rate and rhythm. No extra sounds, clicks, rubs, or murmurs. Capillary refills two seconds. Pulses 3+ throughout. No edema. Respiratory Symmetric chest wall. Respirations regular and easy; lungs clear to auscultation bilaterally. Gastrointestinal
- 7. Abdomen obese; BS active in all the four quadrants. Abdomen soft, nontender. No hepatosplenomegaly. Breast Breast is free from masses or tenderness, no discharge, no dimpling, wrinkling, or discoloration of the skin. Genitourinary Bladder is nondistended; no CVA tenderness. External genitalia reveals coarse pubic hair in normal distribution; skin color is consistent with general pigmentation. No vulvar lesions noted. Well estrogenized. A small speculum was inserted; vaginal walls are pink and well rugated; no lesions noted. Cervix is pink and nulliparous. Scant clear to cloudy drainage present. On bimanual exam, cervix is firm. No CMT. Uterus is antevert and positioned behind a slightly distended bladder; no fullness, masses, or tenderness. No adnexal masses or tenderness. Ovaries are nonpalpable. (Male: Both testes are palpable, no masses or lesions, no hernia, and no uretheral discharge.) (Rectal as appropriate: No evidence of hemorrhoids, fissures, bleeding, or masses—Males: Prostrate is smooth, nontender, and free from nodules, is of normal size, and sphincter tone is firm). Musculoskeletal
- 8. Full ROM seen in all four extremities as the patient moved about the exam room. Neurological Speech clear. Good tone. Posture erect. Balance stable; gait normal. Psychiatric Alert and oriented. Dressed in clean slacks, shirt, and coat. Maintains eye contact. Speech is soft, though clear and of normal rate and cadence; answers questions appropriately. Lab Tests Urinalysis—pending Urine culture—pending Wet prep—pending Special Tests Diagnosis o Include at least three differential diagnosis o Final diagnosis
- 9. Subjective and Objective exams. PLAN including education o Plan: ion treatments -up The Sunrise Enabler The Sunrise Enabler was developed as a tool to guide nurse researchers using the Culture Care Theory. This theory can be the base for qualitative nurse researchers to discover the best culturally relevant nursing care methods. The Sunrise Enabler (SRE) tool is for those looking to describe, explain, interpret someone’s worldview, and cultural meanings, symbols, and
- 10. experiences of someaspect of actual or potential nursing care. I find this tool offers greatinsight as an inquirer into a culture with which one may not be fully familiar. If you look at the SRE,you will note a horizon in the center, with concepts both above and below. Above the horizon, you are looking at major dimensions of any culture and what influencesthe culture and worldview. The goal for the nurse researcheris to use the above-the- horizon information one discovers to address staying healthy, treating illness, and respectfully honor death and dying practices. Now, look below-the-horizon. With cultural findings and insights thus far, one who uses this tool is seeking to respect diverse contexts and consider whether those for whom you are caring use folk practices and or use or accept professional care. Finally, one makes someconclusions about best care proposals for the specific culture: 1) Show respect to preserve/maintain safe/accurate practices 2) Negotiate with individuals/leaders/policy makers to allow folk practices and likely compromises in usual care practices 3) Note and address unsafe/inaccurate understandings
- 11. The SRE helps guide an in-depth examination. One moves back and forth as new information is revealed. The overall goal is to offer culturally relevant care for health, wellbeing, or dying. Is not this also the goal of ministry and missionary care? I propose that this exemplar can be very useful beyond nursing, to otherprofessions that engage in cross-cultural care, such as ministry or missionary experiences. Cecily Strang, RN, BSN, MNsg, PhD Engagement paper instructions The Sunrise Enabler Read Dr. Cecily Strang's description of the Sunrise Enabler while looking at the graphic. (PDFs) Be sure to look at both files, the image and the pdf which is what the follow instruction above is referencing **In a not more that 2-page paper, discuss how you see application of this model to the task of cross cultural ministry and mission.