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Select a patient that you examined during the last four weeks. With this patient in mind, address the following in a SOAP Note: Subjective: What details did the patient provide regarding or her personal and medical history? Objective: What observations did you make during the physical assessment? Assessment: What were your differential diagnoses? Provide a minimum of three possible diagnoses. List them from highest priority to lowest priority. 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, including alternative therapies? Include pharmacologic and nonpharmacologic treatments, alternative therapies, and follow-up parameters, as well as a rationale for this treatment and management plan. Reflection notes: What would you do differently in a similar patient evaluation? (THE TOPIC HERE IS URINARY TRACT INFECTION (UTI) ) please use this format Comprehensive SOAP Template Patient Initials: Age: Gender: F Introduction –Purpose: SUBJECTIVE DATA: Chief Complaint (CC): History of Present Illness (HPI): Medications: Allergies: Seafood, iodine Past Medical History (PMH): Past Surgical History (PSH): Denies. Sexual/Reproductive History (Obstetric) : Personal/Social History: Immunization History and Preventive Care: Significant Family History: . Review of Systems: General : HEENT : Respiratory : Cardiovascular: Breasts: Gastrointestina l: Genitourinary : Musculoskeletal : Psychiatric : Neurological : Dermatological : Hematological and Lymphatic : Endocrine : Allergy and Immunology : OBJECTIVE DATA: Physical Exam: Vital signs: General appearance : HEENT: Neck: Lymphatics: Breasts: Chest: Heart: Abdomen: Neurological: Musculoskeletal: Extremities: Skin: Labs, X-rays, and Diagnostics ASSESSMENT: Priority Diagnosis Differential Diagnosis For each priority diagnosis, list at least three differential diagnoses, each of which must be supported with evidence and guidelines. For holistic care, you need to include previous diagnoses and indicate whether these are controlled or not controlled. These should also be included in your treatment plan. PLAN: Treatment Plan: If applicable, include both pharmacological and non-pharmacological strategies, alternative therapies, follow-up recommendations, referrals, consultations, and any additional labs, x-ray, or other diagnostics. Support the treatment plan with evidence and guidelines. Health Promotion: Include exercise, diet, and safety recommendations, as well as any other health promotion strategies for the patient/family. Support the health promotion recommendations and strategies with evidence and guidelines. Disease Prevention: As appropriate for the patient’s age, include disease prevention recommendations and strategies such as fasting lipid profile, mammography, colonoscopy, immunizations, etc. Sup ...
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Choose one skin condition graphic Shingles # 5 (identify by num.docx
Choose one skin condition graphic Shingles # 5 (identify by number in your Chief Complaint) to document your assignment in the SOAP (Subjective, Objective, Assessment, and Plan) note format rather than the traditional narrative style. Refer to the Comprehensive SOAP Template (see below template). Remember that not all comprehensive SOAP data are included in every patient case.
Use clinical terminologies to explain the physical characteristics featured in the graphic. Formulate a differential diagnosis of
three to five
possible conditions for the skin graphic that you chose. Determine which is most likely to be the correct diagnosis and explain your reasoning using at least three different references, one reference from current evidence-based literature from your search and two different references from Learning Resources.
#5 Shingles
Comprehensive SOAP Template
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 (i.e. 34-year-old AA male). You must include the 7 attributes of
each principal symptom
:
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.
Past Medical History (PMH):
Include illnesses (also childhood illnesses), hospitalizations, and risky sexual behaviors.
Past Surgical History (PSH):
Include dates, indications, and types of operations.
Sexual/Reproductive History: If applicable,
include obstetric history, menstrual history, methods of contraception, and sexual function.
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:
Include last Tdp, Flu, pneumonia, etc.
Significant Family History:
Include history of parents, Grandparents, siblings, and children.
Lifestyle:
Include cultural factors, .
For this Assignment, you will work with an adolescent patient that.docx
For this Assignment, you will work with an adolescent patient that you examined during the last 3 weeks and complete a Focused Note Template in which you will gather patient information, relevant diagnostic and treatment information, and reflect on health promotion and disease prevention in light of patient factors, such as age, ethnic group, past medical history (PMH), socio-economic status, cultural background, etc. In this week’s Learning Resources, please refer to the Focused Note resources for guidance on writing Focused Notes.
Adolescent Patient I saw this week:
A 16-year-old girl and her mother present to your office with concerns about irregular periods. The patient had her first menses at 12 years of age and had regular monthly periods until 6 months ago when her periods stopped. She has had an accompanying 50-pound weight loss over the past 6 months. When asked further about the weight loss, she reports that she has been working on more healthful eating, has cut all desserts and junk foods out of her diet, and eats a low-fat and low-carb diet. In addition she has started running 3 miles a day in order to “get healthy.” On physical exam her vital signs are temperature 36.4°C (97.5°F), heart rate 44 beats per minute, blood pressure 96/60 mm Hg, and respirations 16 breaths per minute. She appears thin, with sallow-looking skin and dry hair. She is bradycardic on exam, with no murmurs and a regular rhythm. Her heart rate increases by 19 beats during positional changes from sitting to standing, with minimal change in her blood pressure. Her pulses are strong and symmetric while her fingers and toes are cool to touch. Anorexia nervosa. Eating disorders are a common but often underdiagnosed condition in the pediatric population.
To prepare:
· Review the Focused Note Checklist provided in this week’s Learning Resources and consider how you will develop your Focused Note for this week’s Assignment.
· Use the Focused SOAP Note Template and the example found in the Learning Resources for this week to complete this Assignment.
· Select an adolescent patient that you examined during the last 3 weeks. With this patient in mind, address the following in a Focused Note.
Assignment
· 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 diagnost.
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:
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Introduction to Evidence Based Medicine (EBM)
This document provides an overview of evidence-based medicine (EBM), including its definition, importance, and process. It defines EBM as the conscientious use of the best available evidence in making decisions about patient care. The key steps in EBM are asking a clear clinical question using the PICO framework, acquiring evidence through a literature search, appraising the evidence for validity and applicability, and applying the evidence to the individual patient. Examples of question types and appropriate study designs are also discussed.
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For this weeks discussion, we will be looking at local or nationa
For this week's discussion, we will be looking at local or national response protocols that were initiated during a critical incident, and you will choose your topic!
Search reputable local and national media for a man-made disaster to discuss.
Search for critical instances such as: hostage situations, mass shootings, multiple-vehicle or mass transit accidents with multiple critical injuries, and disease outbreaks.
In your initial post, describe the incident and address the following:
· Determine the incident type and explain your reasoning.
· What resources were deployed for this incident?
· What protocols were implemented successfully, and which were unsuccessful?
· Discuss way to improve the response to this type of incident in the future.
Support your answer with evidence. Please provide a working link to your story source.
NUR 634 SOAP Note Guide and Template
Patient SOAP Note Charting Procedures
S = Subjective
O = Objective
A = Assessment
P = Plan
Subjective: Information the patient tells the treating team or patient advocate. Symptoms, not signs. These are typically not measurable, such as pain, nausea, and tingling, hence the term “subjective” as opposed to “objective”. Normally, the practitioner is not aware of this information until the patient provides it.
Objective: Information gathered by the treating team or provider which is typically observable and measurable, hence “objective” as opposed to “subjective”. Normally, the patient is not aware of this information until the practitioner elicits it. This might include, for example, ranges of motion, body temperature, blood pressure, the presence of a skin rash or wound, comments about the patient’s posture or gait, and the results of examination procedures and testing.
Assessment: The diagnosis. This must be documented prior to the rendering or delivery of any treatment. Symptom code can be documented as assessment when pending final diagnosis such as Chest pain vs. MI.
Plan: Based on the assessment or diagnosis, the treatment or therapeutic plan must be outlined. This may include both short and long term plans. It is important to record not only passive therapy, such as an injection, a prescription, a spinal manipulation or a massage, but also active therapy such as home care advice, exercises or other recommendations. All treatment planned or delivered must be recorded.
SOAP NOTE TEMPLATE
**Please delete the instructions in each section prior to submitting the assignment
Student Name: Date: Course:
Subjective:
Patient Demographics: (age, gender, gender identity, ethnicity, etc.)
Chief Complaint: “quote patient”
History of Present illness: (Be sure to tell the “story” of the cc using the 7 attributes or OLDCARTS)
PMH: dates in reverse chronological order.
PSH: surgery dates in reverse chronological order.
Allergies: medications, OTCs, supplements, & environmental/seasonal/food allergies
Untoward Medication Reactions: include type ...
see attachments I have complete a portion of the assignment but need
This document outlines the requirements for a diagnostic and clinical reasoning paper assignment. Students are instructed to select a complex patient encounter from their clinical experience. They must document the case using a SOAP format, including sections on subjective assessment, objective findings, assessment, and plan of care. Additionally, students must discuss clinical decision making, pathophysiology, pharmacology, barriers to care, evidence-based practice, and self-reflection on their diagnostic reasoning and role as an advanced practice provider. Strict APA formatting guidelines are required.
Ethics in clinical research
This document discusses ethics in clinical research and medical research. It covers key topics like the principles of ethics, objectives of medical research ethics, functions of medical research, moral problems in clinical research, and ethics requirements. The three main ethical principles are described as justice, respect for persons, and beneficence/non-maleficence. Informed consent, minimizing risks and maximizing benefits, non-exploitation of subjects, and balancing research with patient care are some of the important aspects covered.
Recommended
Choose one skin condition graphic Shingles # 5 (identify by num.docx
Choose one skin condition graphic Shingles # 5 (identify by number in your Chief Complaint) to document your assignment in the SOAP (Subjective, Objective, Assessment, and Plan) note format rather than the traditional narrative style. Refer to the Comprehensive SOAP Template (see below template). Remember that not all comprehensive SOAP data are included in every patient case.
Use clinical terminologies to explain the physical characteristics featured in the graphic. Formulate a differential diagnosis of
three to five
possible conditions for the skin graphic that you chose. Determine which is most likely to be the correct diagnosis and explain your reasoning using at least three different references, one reference from current evidence-based literature from your search and two different references from Learning Resources.
#5 Shingles
Comprehensive SOAP Template
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 (i.e. 34-year-old AA male). You must include the 7 attributes of
each principal symptom
:
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.
Past Medical History (PMH):
Include illnesses (also childhood illnesses), hospitalizations, and risky sexual behaviors.
Past Surgical History (PSH):
Include dates, indications, and types of operations.
Sexual/Reproductive History: If applicable,
include obstetric history, menstrual history, methods of contraception, and sexual function.
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:
Include last Tdp, Flu, pneumonia, etc.
Significant Family History:
Include history of parents, Grandparents, siblings, and children.
Lifestyle:
Include cultural factors, .
For this Assignment, you will work with an adolescent patient that.docx
For this Assignment, you will work with an adolescent patient that you examined during the last 3 weeks and complete a Focused Note Template in which you will gather patient information, relevant diagnostic and treatment information, and reflect on health promotion and disease prevention in light of patient factors, such as age, ethnic group, past medical history (PMH), socio-economic status, cultural background, etc. In this week’s Learning Resources, please refer to the Focused Note resources for guidance on writing Focused Notes.
Adolescent Patient I saw this week:
A 16-year-old girl and her mother present to your office with concerns about irregular periods. The patient had her first menses at 12 years of age and had regular monthly periods until 6 months ago when her periods stopped. She has had an accompanying 50-pound weight loss over the past 6 months. When asked further about the weight loss, she reports that she has been working on more healthful eating, has cut all desserts and junk foods out of her diet, and eats a low-fat and low-carb diet. In addition she has started running 3 miles a day in order to “get healthy.” On physical exam her vital signs are temperature 36.4°C (97.5°F), heart rate 44 beats per minute, blood pressure 96/60 mm Hg, and respirations 16 breaths per minute. She appears thin, with sallow-looking skin and dry hair. She is bradycardic on exam, with no murmurs and a regular rhythm. Her heart rate increases by 19 beats during positional changes from sitting to standing, with minimal change in her blood pressure. Her pulses are strong and symmetric while her fingers and toes are cool to touch. Anorexia nervosa. Eating disorders are a common but often underdiagnosed condition in the pediatric population.
To prepare:
· Review the Focused Note Checklist provided in this week’s Learning Resources and consider how you will develop your Focused Note for this week’s Assignment.
· Use the Focused SOAP Note Template and the example found in the Learning Resources for this week to complete this Assignment.
· Select an adolescent patient that you examined during the last 3 weeks. With this patient in mind, address the following in a Focused Note.
Assignment
· 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 diagnost.
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:
.
Introduction to Evidence Based Medicine (EBM)
This document provides an overview of evidence-based medicine (EBM), including its definition, importance, and process. It defines EBM as the conscientious use of the best available evidence in making decisions about patient care. The key steps in EBM are asking a clear clinical question using the PICO framework, acquiring evidence through a literature search, appraising the evidence for validity and applicability, and applying the evidence to the individual patient. Examples of question types and appropriate study designs are also discussed.
LBDA: Ask the Expert - Daniel Kaufer Live Webinar June 2016
Clinical trials are research studies that test new medical treatments and are conducted according to a research plan called a protocol. A clinical trial has a principal investigator and research team who are responsible for overseeing the trial. Participants must meet eligibility criteria and provide informed consent to enroll. The trial follows a treatment plan, which may involve experimental treatments, standard treatments, or placebos. Participants are monitored by an Institutional Review Board to ensure safety and ethical treatment. Clinical trials provide information about new treatments and help advance medical knowledge, but may not directly benefit participants.
For this weeks discussion, we will be looking at local or nationa
For this week's discussion, we will be looking at local or national response protocols that were initiated during a critical incident, and you will choose your topic!
Search reputable local and national media for a man-made disaster to discuss.
Search for critical instances such as: hostage situations, mass shootings, multiple-vehicle or mass transit accidents with multiple critical injuries, and disease outbreaks.
In your initial post, describe the incident and address the following:
· Determine the incident type and explain your reasoning.
· What resources were deployed for this incident?
· What protocols were implemented successfully, and which were unsuccessful?
· Discuss way to improve the response to this type of incident in the future.
Support your answer with evidence. Please provide a working link to your story source.
NUR 634 SOAP Note Guide and Template
Patient SOAP Note Charting Procedures
S = Subjective
O = Objective
A = Assessment
P = Plan
Subjective: Information the patient tells the treating team or patient advocate. Symptoms, not signs. These are typically not measurable, such as pain, nausea, and tingling, hence the term “subjective” as opposed to “objective”. Normally, the practitioner is not aware of this information until the patient provides it.
Objective: Information gathered by the treating team or provider which is typically observable and measurable, hence “objective” as opposed to “subjective”. Normally, the patient is not aware of this information until the practitioner elicits it. This might include, for example, ranges of motion, body temperature, blood pressure, the presence of a skin rash or wound, comments about the patient’s posture or gait, and the results of examination procedures and testing.
Assessment: The diagnosis. This must be documented prior to the rendering or delivery of any treatment. Symptom code can be documented as assessment when pending final diagnosis such as Chest pain vs. MI.
Plan: Based on the assessment or diagnosis, the treatment or therapeutic plan must be outlined. This may include both short and long term plans. It is important to record not only passive therapy, such as an injection, a prescription, a spinal manipulation or a massage, but also active therapy such as home care advice, exercises or other recommendations. All treatment planned or delivered must be recorded.
SOAP NOTE TEMPLATE
**Please delete the instructions in each section prior to submitting the assignment
Student Name: Date: Course:
Subjective:
Patient Demographics: (age, gender, gender identity, ethnicity, etc.)
Chief Complaint: “quote patient”
History of Present illness: (Be sure to tell the “story” of the cc using the 7 attributes or OLDCARTS)
PMH: dates in reverse chronological order.
PSH: surgery dates in reverse chronological order.
Allergies: medications, OTCs, supplements, & environmental/seasonal/food allergies
Untoward Medication Reactions: include type ...
see attachments I have complete a portion of the assignment but need
This document outlines the requirements for a diagnostic and clinical reasoning paper assignment. Students are instructed to select a complex patient encounter from their clinical experience. They must document the case using a SOAP format, including sections on subjective assessment, objective findings, assessment, and plan of care. Additionally, students must discuss clinical decision making, pathophysiology, pharmacology, barriers to care, evidence-based practice, and self-reflection on their diagnostic reasoning and role as an advanced practice provider. Strict APA formatting guidelines are required.
Ethics in clinical research
This document discusses ethics in clinical research and medical research. It covers key topics like the principles of ethics, objectives of medical research ethics, functions of medical research, moral problems in clinical research, and ethics requirements. The three main ethical principles are described as justice, respect for persons, and beneficence/non-maleficence. Informed consent, minimizing risks and maximizing benefits, non-exploitation of subjects, and balancing research with patient care are some of the important aspects covered.
Develop a Focused SOAP including your differential diagnosis and.docx
The patient presented with chief complaints of depressed mood and lack of motivation for 3 months. On examination, the patient displayed depressed affect and psychomotor retardation. The differential diagnoses were major depressive disorder, bipolar disorder, and generalized anxiety disorder. Major depressive disorder best fit the DSM-5 criteria based on duration of symptoms and lack of manic episodes. The treatment plan included antidepressant medication and cognitive behavioral therapy with follow up in 4 weeks. Future interventions and consideration of legal/ethical issues were discussed.
Presentation on medication history interview and soap notes
pharmacy practice is vital activity performed by pharmadians along with physicians to enhance the quality and span of life of patient .mediaction history interview is is an essential to know and presentation of case collected in universally accepted format .
Diagnostic and Clinical Reasoning Paper AssignmentThe purpos
Diagnostic and Clinical Reasoning Paper Assignment
The purpose of this assignment is to provide you the opportunity to expand the scope of your clinical documentation and your thought processes relative to complex patient care cases.
1. Select a patient encounter from your current clinical experience.
2. The patient encounter you select should be one of the more complex patient cases that you have experienced with your current clinical patient population. Given that you are to select complex cases, this assignment may not be completed for a ‘general health, well child, well woman, routine OB, routine physical exam (etc.)’ type of encounter.
You will need to identify which patient encounter you are expanding your documentation for by including the Typhon Case ID # under your name on the title page of your paper.
3. For this assignment you will utilize the same SOAP format that you do for your ‘expanded’ Typhon encounters. Construct this assignment ensuring that you adhere to the writing guidelines provided in the 6th edition APA manual.
Below is the overview of the required elements for this assignment:
*Title Page
(Page 1)
:
Follow APA guidelines for running head on page 1, and include Medical Diagnosis, Student Name, Typhon Case ID #, and Date.
*Subjective
(Start of Page 2)
:
Follow APA guidelines for running head on page 2 and subsequent pages.
CC:
chief complaint - What are they being seen for? This is the reason that the patient sought care, stated in their own words, or paraphrased.
HPI:
history of present illness - use the “OLDCART” approach for collecting data and documenting findings. [O=onset, L=location, D=duration, C=characteristics, A=associated/aggravating factors, R=relieving Factors, T=treatment, S=summary]
PMH:
past medical history - This should include past illness/diagnosis, conditions, traumas, hospitalizations, and surgical history. Include dates if possible.
Allergies:
State the offending medication/food and the reactions.
Medications:
Names, dosages, and routes of administration.
Social history:
Related to the problem, educational level/literacy, smoking, alcohol, drugs, HIV risk, sexually active, caffeine, work and other stressors. Cultural and spiritual beliefs that impact health and illness. Financial resources.
Click on the link below to explore the CDC’s information on the ‘social determinants of health’.
https://www.cdc.gov/socialdeterminants/
Family history:
Use terms like maternal, paternal and the diseases and the ages they were deceased or diagnosed if known.
Health Maintenance/Promotion:
Immunizations, exercise, diet, etc. Remember to use the United States Clinical Preventative Services Task Force (USPSTF) guidelines for age appropriate indicators. This should reflect what the patient is presently doing regarding the guidelines.
Click on the link below to access information about current guidelines.
https://www.uspreventiveservicestaskforce.org/
Review of Systems (R ...
For this assignment, you are to complete aclinical case - narrat.docx
For this assignment, you are to complete a
clinical case - narrated PowerPoint report
that will follow the SOAP note example provided below. The case report will be based on the clinical case scenario list below.
You are to approach this clinical scenario as if it is a real patient in the clinical setting.
Instructions:
Step 1
- Read the assigned clinical scenario and using your clinical reasoning skills, decide on the diagnoses. This step informs your next steps.
Step 2
- Document the given information in the case scenario under the appropriate sections, headings, and subheadings of the SOAP note.
Step 3
- Document all the classic symptoms typically associated with the diagnoses in Step 1. This information may NOT be given in the scenario; you are to obtain this information from your textbooks. Include APA citations.
Example of Steps 1 - 3:
You decided on Angina after reading the clinical case scenario (Step 1)
Review of Symptoms (list of classic symptoms):
CV: sweating, squeezing, pressure, heaviness, tightening, burning across the chest starting behind the breastbone
GI: indigestion, heartburn, nausea, cramping
Pain: pain to the neck, jaw, arms, shoulders, throat, back, and teeth
Resp: shortness of breath
Musculo: weakness
Step 4
– Document the abnormal physical exam findings typically associated with the acute and chronic diagnoses decided on in Step 1. Again, this information may NOT be given. Cull this information from the textbooks. Include APA citations.
Example of Step 4:
You determined the patient has Angina in Step 1
Physical Examination (list of classic exam findings):
CV: RRR, murmur grade 1/4
Resp: diminished breath sounds left lower lobe
Step 5
- Document the diagnoses in the appropriate sections, including the ICD-10 codes, from Step 1. Include three differential diagnoses. Define each diagnosis and support each differential diagnosis with pertinent positives and negatives and what makes these choices plausible. This information may come from your textbooks. Remember to cite using APA.
Step 6
- Develop a treatment plan for the diagnoses.
Only
use National Clinical Guidelines to develop your treatment plans. This information will not come from your textbooks. Use your research skills to locate appropriate guidelines. The treatment plan
must
address the following:
a) Medications (include the dosage in mg/kg, frequency, route, and the number of days)
b) Laboratory tests ordered (include why ordered and what the results of the test may indicate)
c) Diagnostic tests ordered (include why ordered and what the results of the test may indicate)
d) Vaccines administered this visit & vaccine administration forms given,
e) Non-pharmacological treatments
f) Patient/Family education including preventive care
g) Anticipatory guidance for the visit (be sure to include exactly what you discussed during the visit; review Bright Futures website for this section)
h) Follow-up appointment with a.
Clinical trial
This document discusses clinical trials, including their objectives, key aspects, and participating parties. The main points are:
Clinical trials examine and evaluate the safety and efficacy of therapies in human subjects. Their objectives include developing protocols, screening and enrolling participants, monitoring safety, and generating reports. Key elements are experimental units (subjects), treatments being tested, and ways of evaluating outcomes. Clinical trials involve various parties like sponsors, investigators and their teams, reviewing ethics boards, institutions hosting the trials, and regulatory authorities. They progress through defined pre-clinical and phases I-IV to develop therapies and ensure subjects' protection.
How to make a case presentation
This document outlines how to present a case using the SOAP format. It includes sections for Subjective evidence (S) such as patient demographics, chief complaints, medical history, physical exam findings and provisional diagnosis. Objective evidence (O) such as lab results and investigations. Assessment (A) which is the final diagnosis. And Plan (P) which contains the proposed treatment plan, goals, medications, monitoring for interactions or errors, and pharmacist interventions.
For this assignment, you are to complete aclinical case - narr.docx
For this assignment, you are to complete a
clinical case - narrated PowerPoint report
that will follow the SOAP note example provided below. The case report will be based on the clinical case scenario list below.
You are to approach this clinical scenario as if it is a real patient in the clinical setting.
Instructions:
Step 1
- Read the assigned clinical scenario and using your clinical reasoning skills, decide on the diagnoses. This step informs your next steps.
Step 2
- Document the given information in the case scenario under the appropriate sections, headings, and subheadings of the SOAP note.
Step 3
- Document all the classic symptoms typically associated with the diagnoses in Step 1. This information may NOT be given in the scenario; you are to obtain this information from your textbooks. Include APA citations.
Example of Steps 1 - 3:
You decided on Angina after reading the clinical case scenario (Step 1)
Review of Symptoms (list of classic symptoms):
CV: sweating, squeezing, pressure, heaviness, tightening, burning across the chest starting behind the breastbone
GI: indigestion, heartburn, nausea, cramping
Pain: pain to the neck, jaw, arms, shoulders, throat, back, and teeth
Resp: shortness of breath
Musculo: weakness
Step 4
– Document the abnormal physical exam findings typically associated with the acute and chronic diagnoses decided on in Step 1. Again, this information may NOT be given. Cull this information from the textbooks. Include APA citations.
Example of Step 4:
You determined the patient has Angina in Step 1
Physical Examination (list of classic exam findings):
CV: RRR, murmur grade 1/4
Resp: diminished breath sounds left lower lobe
Step 5
- Document the diagnoses in the appropriate sections, including the ICD-10 codes, from Step 1. Include three differential diagnoses. Define each diagnosis and support each differential diagnosis with pertinent positives and negatives and what makes these choices plausible. This information may come from your textbooks. Remember to cite using APA.
Step 6
- Develop a treatment plan for the diagnoses.
Only
use National Clinical Guidelines to develop your treatment plans. This information will not come from your textbooks. Use your research skills to locate appropriate guidelines. The treatment plan
must
address the following:
a) Medications (include the dosage in mg/kg, frequency, route, and the number of days)
b) Laboratory tests ordered (include why ordered and what the results of the test may indicate)
c) Diagnostic tests ordered (include why ordered and what the results of the test may indicate)
d) Vaccines administered this visit & vaccine administration forms given,
e) Non-pharmacological treatments
f) Patient/Family education including preventive care
g) Anticipatory guidance for the visit (be sure to include exactly what you discussed during the visit; review Bright Futures website for this section)
h) Follow-up appointment wit.
Evidence Based Practice and Finding the Information You Need
EBP presentation geared towards Physical Therapy students enrolled in PT 610 at the University of South Alabama
Evidence Based Practice, a 5.5 Min Intro
Evidence-based practice involves using the best available research evidence along with clinical expertise and patient preferences to make decisions about patient care. Systematic reviews summarize healthcare research to aid this process. An example is a provider recommending acetaminophen over other pain relievers to a patient with a history of stomach bleeding due to research showing it poses less risk of stomach bleeds. The process of evidence-based practice involves assessing the patient, asking a question, acquiring evidence, appraising the evidence, applying it while considering expertise, preferences and re-evaluating performance.
Clinical Trial Recruitment
Our main involvement with your clinical research recruitment program concludes with processing the responses to your mailer. As our staff members direct the respondents to your site, you can begin conducting final interviews to complete the clinical trial recruitment process.
NRNPPRAC 6665 & 6675 Focused SOAP Psychiatric Evaluation Exemplar.docx
NRNP/PRAC 6665 & 6675 Focused SOAP Psychiatric Evaluation Exemplar
INSTRUCTIONS ON HOW TO USE EXEMPLAR AND TEMPLATE—READ CAREFULLY
If you are struggling with the format or remembering what to include, follow the
Focused SOAP Note Evaluation Template
AND the Rubric
as your guide. It is also helpful to review the rubric in detail in order not to lose points unnecessarily because you missed something required. After reviewing full details of the rubric, you can use it as a guide.
In the
Subjective section, provide:
· Chief complaint
· History of present illness (HPI)
· Past psychiatric history
· Medication trials and current medications
· Psychotherapy or previous psychiatric diagnosis
· Pertinent substance use, family psychiatric/substance use, social, and medical history
· Allergies
· ROS
Read rating descriptions to see the grading standards!
In the
Objective section, provide:
· Physical exam documentation of systems pertinent to the chief complaint, HPI, and history
· Diagnostic results, including any labs, imaging, or other assessments needed to develop the differential diagnoses.
Read rating descriptions to see the grading standards!
In the
Assessment section, provide:
· Results of the mental status examination,
presented in paragraph form.
· At least three differentials with supporting evidence. List them from top priority to least priority. Compare the
DSM-5-TR diagnostic criteria for each differential diagnosis and explain what
DSM-5-TR criteria rules out the differential diagnosis to find an accurate diagnosis.
Explain the critical-thinking process that led you to the primary diagnosis you selected. Include pertinent positives and pertinent negatives for the specific patient case.
·
Read rating descriptions to see the grading standards!
Reflect on this case. Include: Discuss what you learned and what you might do differently. Also include in your reflection a discussion related to legal/ethical considerations (
demonstrate critical thinking beyond confidentiality and consent for treatment!), social determinates of health, health promotion and disease prevention taking into consideration patient factors (such as age, ethnic group, etc.), PMH, and other risk factors (e.g., socioeconomic, cultural background, etc.).
(The FOCUSED SOAP psychiatric evaluation is typically the
follow-up visit patient note. You will practice writing this type of note in this course. You will be focusing more on the symptoms from your differential diagnosis from the comprehensive psychiatric evaluation narrowing to your diagnostic impression. You will write up what symptoms are present and what symptoms are not present from illnesses to demonstrate you have indeed assessed for illnesses which could be impacting your patient. For ex.
How to write An Evidence Based Article?
The document provides guidelines for writing an evidence-based review article. It defines different types of review articles and outlines the key steps, which include: selecting a topic of clinical relevance; conducting a comprehensive literature search of sources like systematic reviews and clinical practice guidelines; evaluating the strength and validity of the evidence; and presenting the information in a standardized format covering introduction, methods, discussion, and references. The discussion section should provide an evidence-based analysis of a topic, acknowledge any controversies, and rate the level of evidence for key statements and recommendations.
[removed]NRNPPRAC 6665 & 6675 Focused SOAP Psychiatric Evaluati.docx
[removed]
NRNP/PRAC 6665 & 6675 Focused SOAP Psychiatric Evaluation Exemplar
INSTRUCTIONS ON HOW TO USE EXEMPLAR AND TEMPLATE—READ CAREFULLY
If you are struggling with the format or remembering what to include, follow the
Focused SOAP Note Evaluation Template
AND the Rubric
as your guide. It is also helpful to review the rubric in detail in order not to lose points unnecessarily because you missed something required. After reviewing full details of the rubric, you can use it as a guide.
In the
Subjective section, provide:
· Chief complaint
· History of present illness (HPI)
· Past psychiatric history
· Medication trials and current medications
· Psychotherapy or previous psychiatric diagnosis
· Pertinent substance use, family psychiatric/substance use, social, and medical history
· Allergies
· ROS
Read rating descriptions to see the grading standards!
In the
Objective section, provide:
· Physical exam documentation of systems pertinent to the chief complaint, HPI, and history
· Diagnostic results, including any labs, imaging, or other assessments needed to develop the differential diagnoses.
Read rating descriptions to see the grading standards!
In the
Assessment section, provide:
· Results of the mental status examination,
presented in paragraph form.
· At least three differentials with supporting evidence. List them from top priority to least priority. Compare the
DSM-5-TR diagnostic criteria for each differential diagnosis and explain what
DSM-5-TR criteria rules out the differential diagnosis to find an accurate diagnosis.
Explain the critical-thinking process that led you to the primary diagnosis you selected. Include pertinent positives and pertinent negatives for the specific patient case.
·
Read rating descriptions to see the grading standards!
Reflect on this case. Include: Discuss what you learned and what you might do differently. Also include in your reflection a discussion related to legal/ethical considerations (
demonstrate critical thinking beyond confidentiality and consent for treatment!), social determinates of health, health promotion and disease prevention taking into consideration patient factors (such as age, ethnic group, etc.), PMH, and other risk factors (e.g., socioeconomic, cultural background, etc.).
(The FOCUSED SOAP psychiatric evaluation is typically the
follow-up visit patient note. You will practice writing this type of note in this course. You will be focusing more on the symptoms from your differential diagnosis from the comprehensive psychiatric evaluation narrowing to your diagnostic impression. You will write up what symptoms are present and what symptoms are not present from illnesses to demonstrate you have indeed assessed for illnesses which could be impacting your patient. For .
CASE STUDYFemale, 15, separation anxiety disorder, Depression.docx
CASE STUDY:
Female, 15, separation anxiety disorder, Depression
The patient is a fifteen-year-old female teenager who presents to the clinic with her mother for her first assessment. Patient is being referral to the clinic by the school counselor due to low grades and poor school assistance. During the session, both the patient and the mother are neatly dressed. Her mother seems to be worried about her daughter. The patient said, "I worry a lot about my family members. I fear that one day my parents will be abducted or fatally injured. The worries and fears make me have difficulties concentrating on personal well-being and my studies in school." The mental assessment shows that the patient is depressed, and she refuses to leave the proximity of her mother. Her mother says that her daughter has been experiencing depression or anxiety attacks. The physical assessment shows that the patient has been experiencing physical aches and pains. She maintains good eye contact. Her mood is a little anxious. The symptoms conclude that the patient has separation anxiety disorder because the symptoms have progressed for the past six months. Treatments include antidepressants, group therapy, family therapy, dialectical behavioral therapy, and cognitive-behavioral therapy. A follow-up is to be done in two weeks.
Assignment 2: Focused SOAP Note and Patient Case Presentation
Psychiatric notes are a way to reflect on your practicum experiences and connect them to the didactic learning you gain from your NRNP courses. Focused SOAP notes, such as the ones required in this practicum course, are often used in clinical settings to document patient care.
For this Assignment, you will document information about a patient that you examined during the last three weeks, using the Focused SOAP Note Template provided. You will then use this note to develop and record a case presentation for this patient.
To Prepare
· Present the full complex case study. Include chief complaint; history of present illness; any pertinent past psychiatric, substance use, medical, social, family history; most recent mental status exam; current psychiatric diagnosis including differentials that were ruled out; and plan for treatment and management.
· Report normal diagnostic results as the name of the test and “normal” (rather than specific value). Abnormal results should be reported as a specific value.
· Specifically address the following for the patient, using your SOAP note as a guide:
·
Subjective: What details did the patient provide regarding their chief complaint and symptomology to derive your differential diagnosis? What is the duration and severity of their symptoms? How are their symptoms impacting their functioning in life?
·
Objective: What observations did you make during the psychiatric assessment?
·
Assessment: Discuss their mental status examination results. What were your differential diagnoses? Provide a minimum o.
NURS 6512 Assessment Tools and Diagnostic Tests.pdf
This document discusses three case studies of patients from diverse backgrounds presenting for physical exams. It prompts the reader to reflect on one case study and the cultural factors relevant to that patient's health. These include socioeconomic status, spirituality, lifestyle, and culture. The reader is asked to consider sensitive questions to build the patient's health history while being aware of their background. The goal is for healthcare providers to properly assess patients from a variety of populations.
History taking By Muhammad Arslan Yasin
History Taking
1.Name, age, sex, marital status, occupation, address (Demographics)
2. Presenting complaints
3. History of present illness
4. Systemic inquiry
5. Past history
6. Menstrual history
7. Treatment history
8. Family history
9. Personal and social history
10. Occupational history
Healthcare -- putting prevention into practice
This slidedeck is submitted by Zafar Hasan because one of the trends in medicine for the last 20 years isa focus on prevention and this deck is an outstanding practice primer.
Searching For The Evidence
- The document discusses evidence-based practice (EBP) and how to formulate clinical questions and search for evidence using databases and subject headings.
- The EBP process involves identifying a problem, developing a focused clinical question using PICO (population, intervention, comparison, outcome), searching relevant resources, critically appraising the evidence, and implementing in practice.
- Useful databases for finding evidence include CINAHL, MEDLINE, Cochrane Library. Subject headings and filters can help narrow search results.
You have been provided with case study in Week 4 that focused on.docx
You have been provided with case study in
Week 4
that focused on genitourinary .You will analyze and create a comprehensive plan of care for acute/chronic care, disease prevention, and health promotion for that patient and disorder. Your care plan should be based on current best practices and supported with citations from current literature, such as systematic reviews, published practice guidelines, standards of care from specialty organizations, and other research based resources. In addition, you will provide a detailed scientific rationale that justifies the inclusion of this evidence in your plan. Your paper should adhere to APA format for title page, headings, citations, and references. The paper should be no more than 3 pages typed excluding title page and references.
Criteria:
SOAP note
Evaluation of priority diagnosis
Facilitators and barriers to disorder management
Assignment 2 Grading Criteria
Maximum Points
Introduction
The submission included a general introduction to the priority diagnosis.
10
Subjective Data
The submission included the patient's interpretation of current medical problem. It included chief complaint, history of present illness, current medications and reason prescribed, past medical history, family history, and review of systems.
15
Objective Data
The submission included the measurements and observations obtained by the nurse practitioner. It included head to toe physical examination, laboratory and diagnostic testing results.
15
Assessment
The submission included at least three priority diagnoses. Each diagnosis was supported by documentation in subjective and objective notes and free of essential omissions. All diagnoses were documented using acceptable terminologies and current ICD-10 codes.
20
Plan of Care
Plan included diagnostic and therapeutic (pharmacologic and non-pharmacologic) management as well as education and counseling provided. The plan was supported by evidence/guidelines, and the follow-up plans were noted.
25
Evaluation of Priority Diagnosis
The plan chose the priority diagnosis for the pt and differentiated the disorder from normal development. Discussed the physical and psychological demands the disorder places on the patient and family and key concepts to discuss with them. Identified key interdisciplinary team personnel needed and how this team will provide care to achieve optimal disorder management and outcomes.
25
Facilitators and Barriers
The submission interpreted facilitators and barriers to optimal disorder management and outcomes and strategies to overcome the identified barriers.
20
Conclusion
The submission included what should be taken away from this assignment.
10
APA/Style/Format
The submission was free of grammatical, spelling, or punctuation errors. Citations and references were written in correct APA Style.
Utilized proper format with coversheet, header.
10
Total
150
.
Patient Assessment And Clinical Interviewing
The document provides guidance on common mistakes healthcare practitioners make in patient communication and assessment. It discusses the importance of greeting patients, understanding their concerns, asking open-ended questions, being attentive to verbal and non-verbal cues, avoiding judgements, and understanding cultural beliefs. It also outlines key information to collect during a patient assessment, including medical history, medications, allergies and social factors, and provides examples of documentation through a SOAP note.
Natural Selection and Patterns of Evolution WorksheetComplet.docx
This document provides a worksheet with questions about natural selection and patterns of evolution. The worksheet asks students to write short answers in 100 to 200 words for each question. The questions cover direct evidence that supports the theory of natural selection such as examples; whether humans are subject to the same pressures of natural selection as other organisms and why; examples of convergent evolution, divergent evolution, adaptive radiation and co-evolution and implications one example may have for future humans; and how a new species evolves from a pre-existing species including factors affecting speciation.
Navigate to the Pearson Assessment website. Identify an assessme.docx
This document discusses selecting an assessment from the Pearson Assessment website for diagnostic purposes. It asks the reader to identify a specific assessment, the diagnosis it is intended for, and attributes to consider when matching a client to the test.
More Related Content
Similar to Select a patient that you examined during the last four weeks. W.docx
Develop a Focused SOAP including your differential diagnosis and.docx
The patient presented with chief complaints of depressed mood and lack of motivation for 3 months. On examination, the patient displayed depressed affect and psychomotor retardation. The differential diagnoses were major depressive disorder, bipolar disorder, and generalized anxiety disorder. Major depressive disorder best fit the DSM-5 criteria based on duration of symptoms and lack of manic episodes. The treatment plan included antidepressant medication and cognitive behavioral therapy with follow up in 4 weeks. Future interventions and consideration of legal/ethical issues were discussed.
Presentation on medication history interview and soap notes
pharmacy practice is vital activity performed by pharmadians along with physicians to enhance the quality and span of life of patient .mediaction history interview is is an essential to know and presentation of case collected in universally accepted format .
Diagnostic and Clinical Reasoning Paper AssignmentThe purpos
Diagnostic and Clinical Reasoning Paper Assignment
The purpose of this assignment is to provide you the opportunity to expand the scope of your clinical documentation and your thought processes relative to complex patient care cases.
1. Select a patient encounter from your current clinical experience.
2. The patient encounter you select should be one of the more complex patient cases that you have experienced with your current clinical patient population. Given that you are to select complex cases, this assignment may not be completed for a ‘general health, well child, well woman, routine OB, routine physical exam (etc.)’ type of encounter.
You will need to identify which patient encounter you are expanding your documentation for by including the Typhon Case ID # under your name on the title page of your paper.
3. For this assignment you will utilize the same SOAP format that you do for your ‘expanded’ Typhon encounters. Construct this assignment ensuring that you adhere to the writing guidelines provided in the 6th edition APA manual.
Below is the overview of the required elements for this assignment:
*Title Page
(Page 1)
:
Follow APA guidelines for running head on page 1, and include Medical Diagnosis, Student Name, Typhon Case ID #, and Date.
*Subjective
(Start of Page 2)
:
Follow APA guidelines for running head on page 2 and subsequent pages.
CC:
chief complaint - What are they being seen for? This is the reason that the patient sought care, stated in their own words, or paraphrased.
HPI:
history of present illness - use the “OLDCART” approach for collecting data and documenting findings. [O=onset, L=location, D=duration, C=characteristics, A=associated/aggravating factors, R=relieving Factors, T=treatment, S=summary]
PMH:
past medical history - This should include past illness/diagnosis, conditions, traumas, hospitalizations, and surgical history. Include dates if possible.
Allergies:
State the offending medication/food and the reactions.
Medications:
Names, dosages, and routes of administration.
Social history:
Related to the problem, educational level/literacy, smoking, alcohol, drugs, HIV risk, sexually active, caffeine, work and other stressors. Cultural and spiritual beliefs that impact health and illness. Financial resources.
Click on the link below to explore the CDC’s information on the ‘social determinants of health’.
https://www.cdc.gov/socialdeterminants/
Family history:
Use terms like maternal, paternal and the diseases and the ages they were deceased or diagnosed if known.
Health Maintenance/Promotion:
Immunizations, exercise, diet, etc. Remember to use the United States Clinical Preventative Services Task Force (USPSTF) guidelines for age appropriate indicators. This should reflect what the patient is presently doing regarding the guidelines.
Click on the link below to access information about current guidelines.
https://www.uspreventiveservicestaskforce.org/
Review of Systems (R ...
For this assignment, you are to complete aclinical case - narrat.docx
For this assignment, you are to complete a
clinical case - narrated PowerPoint report
that will follow the SOAP note example provided below. The case report will be based on the clinical case scenario list below.
You are to approach this clinical scenario as if it is a real patient in the clinical setting.
Instructions:
Step 1
- Read the assigned clinical scenario and using your clinical reasoning skills, decide on the diagnoses. This step informs your next steps.
Step 2
- Document the given information in the case scenario under the appropriate sections, headings, and subheadings of the SOAP note.
Step 3
- Document all the classic symptoms typically associated with the diagnoses in Step 1. This information may NOT be given in the scenario; you are to obtain this information from your textbooks. Include APA citations.
Example of Steps 1 - 3:
You decided on Angina after reading the clinical case scenario (Step 1)
Review of Symptoms (list of classic symptoms):
CV: sweating, squeezing, pressure, heaviness, tightening, burning across the chest starting behind the breastbone
GI: indigestion, heartburn, nausea, cramping
Pain: pain to the neck, jaw, arms, shoulders, throat, back, and teeth
Resp: shortness of breath
Musculo: weakness
Step 4
– Document the abnormal physical exam findings typically associated with the acute and chronic diagnoses decided on in Step 1. Again, this information may NOT be given. Cull this information from the textbooks. Include APA citations.
Example of Step 4:
You determined the patient has Angina in Step 1
Physical Examination (list of classic exam findings):
CV: RRR, murmur grade 1/4
Resp: diminished breath sounds left lower lobe
Step 5
- Document the diagnoses in the appropriate sections, including the ICD-10 codes, from Step 1. Include three differential diagnoses. Define each diagnosis and support each differential diagnosis with pertinent positives and negatives and what makes these choices plausible. This information may come from your textbooks. Remember to cite using APA.
Step 6
- Develop a treatment plan for the diagnoses.
Only
use National Clinical Guidelines to develop your treatment plans. This information will not come from your textbooks. Use your research skills to locate appropriate guidelines. The treatment plan
must
address the following:
a) Medications (include the dosage in mg/kg, frequency, route, and the number of days)
b) Laboratory tests ordered (include why ordered and what the results of the test may indicate)
c) Diagnostic tests ordered (include why ordered and what the results of the test may indicate)
d) Vaccines administered this visit & vaccine administration forms given,
e) Non-pharmacological treatments
f) Patient/Family education including preventive care
g) Anticipatory guidance for the visit (be sure to include exactly what you discussed during the visit; review Bright Futures website for this section)
h) Follow-up appointment with a.
Clinical trial
This document discusses clinical trials, including their objectives, key aspects, and participating parties. The main points are:
Clinical trials examine and evaluate the safety and efficacy of therapies in human subjects. Their objectives include developing protocols, screening and enrolling participants, monitoring safety, and generating reports. Key elements are experimental units (subjects), treatments being tested, and ways of evaluating outcomes. Clinical trials involve various parties like sponsors, investigators and their teams, reviewing ethics boards, institutions hosting the trials, and regulatory authorities. They progress through defined pre-clinical and phases I-IV to develop therapies and ensure subjects' protection.
How to make a case presentation
This document outlines how to present a case using the SOAP format. It includes sections for Subjective evidence (S) such as patient demographics, chief complaints, medical history, physical exam findings and provisional diagnosis. Objective evidence (O) such as lab results and investigations. Assessment (A) which is the final diagnosis. And Plan (P) which contains the proposed treatment plan, goals, medications, monitoring for interactions or errors, and pharmacist interventions.
For this assignment, you are to complete aclinical case - narr.docx
For this assignment, you are to complete a
clinical case - narrated PowerPoint report
that will follow the SOAP note example provided below. The case report will be based on the clinical case scenario list below.
You are to approach this clinical scenario as if it is a real patient in the clinical setting.
Instructions:
Step 1
- Read the assigned clinical scenario and using your clinical reasoning skills, decide on the diagnoses. This step informs your next steps.
Step 2
- Document the given information in the case scenario under the appropriate sections, headings, and subheadings of the SOAP note.
Step 3
- Document all the classic symptoms typically associated with the diagnoses in Step 1. This information may NOT be given in the scenario; you are to obtain this information from your textbooks. Include APA citations.
Example of Steps 1 - 3:
You decided on Angina after reading the clinical case scenario (Step 1)
Review of Symptoms (list of classic symptoms):
CV: sweating, squeezing, pressure, heaviness, tightening, burning across the chest starting behind the breastbone
GI: indigestion, heartburn, nausea, cramping
Pain: pain to the neck, jaw, arms, shoulders, throat, back, and teeth
Resp: shortness of breath
Musculo: weakness
Step 4
– Document the abnormal physical exam findings typically associated with the acute and chronic diagnoses decided on in Step 1. Again, this information may NOT be given. Cull this information from the textbooks. Include APA citations.
Example of Step 4:
You determined the patient has Angina in Step 1
Physical Examination (list of classic exam findings):
CV: RRR, murmur grade 1/4
Resp: diminished breath sounds left lower lobe
Step 5
- Document the diagnoses in the appropriate sections, including the ICD-10 codes, from Step 1. Include three differential diagnoses. Define each diagnosis and support each differential diagnosis with pertinent positives and negatives and what makes these choices plausible. This information may come from your textbooks. Remember to cite using APA.
Step 6
- Develop a treatment plan for the diagnoses.
Only
use National Clinical Guidelines to develop your treatment plans. This information will not come from your textbooks. Use your research skills to locate appropriate guidelines. The treatment plan
must
address the following:
a) Medications (include the dosage in mg/kg, frequency, route, and the number of days)
b) Laboratory tests ordered (include why ordered and what the results of the test may indicate)
c) Diagnostic tests ordered (include why ordered and what the results of the test may indicate)
d) Vaccines administered this visit & vaccine administration forms given,
e) Non-pharmacological treatments
f) Patient/Family education including preventive care
g) Anticipatory guidance for the visit (be sure to include exactly what you discussed during the visit; review Bright Futures website for this section)
h) Follow-up appointment wit.
Evidence Based Practice and Finding the Information You Need
EBP presentation geared towards Physical Therapy students enrolled in PT 610 at the University of South Alabama
Evidence Based Practice, a 5.5 Min Intro
Evidence-based practice involves using the best available research evidence along with clinical expertise and patient preferences to make decisions about patient care. Systematic reviews summarize healthcare research to aid this process. An example is a provider recommending acetaminophen over other pain relievers to a patient with a history of stomach bleeding due to research showing it poses less risk of stomach bleeds. The process of evidence-based practice involves assessing the patient, asking a question, acquiring evidence, appraising the evidence, applying it while considering expertise, preferences and re-evaluating performance.
Clinical Trial Recruitment
Our main involvement with your clinical research recruitment program concludes with processing the responses to your mailer. As our staff members direct the respondents to your site, you can begin conducting final interviews to complete the clinical trial recruitment process.
NRNPPRAC 6665 & 6675 Focused SOAP Psychiatric Evaluation Exemplar.docx
NRNP/PRAC 6665 & 6675 Focused SOAP Psychiatric Evaluation Exemplar
INSTRUCTIONS ON HOW TO USE EXEMPLAR AND TEMPLATE—READ CAREFULLY
If you are struggling with the format or remembering what to include, follow the
Focused SOAP Note Evaluation Template
AND the Rubric
as your guide. It is also helpful to review the rubric in detail in order not to lose points unnecessarily because you missed something required. After reviewing full details of the rubric, you can use it as a guide.
In the
Subjective section, provide:
· Chief complaint
· History of present illness (HPI)
· Past psychiatric history
· Medication trials and current medications
· Psychotherapy or previous psychiatric diagnosis
· Pertinent substance use, family psychiatric/substance use, social, and medical history
· Allergies
· ROS
Read rating descriptions to see the grading standards!
In the
Objective section, provide:
· Physical exam documentation of systems pertinent to the chief complaint, HPI, and history
· Diagnostic results, including any labs, imaging, or other assessments needed to develop the differential diagnoses.
Read rating descriptions to see the grading standards!
In the
Assessment section, provide:
· Results of the mental status examination,
presented in paragraph form.
· At least three differentials with supporting evidence. List them from top priority to least priority. Compare the
DSM-5-TR diagnostic criteria for each differential diagnosis and explain what
DSM-5-TR criteria rules out the differential diagnosis to find an accurate diagnosis.
Explain the critical-thinking process that led you to the primary diagnosis you selected. Include pertinent positives and pertinent negatives for the specific patient case.
·
Read rating descriptions to see the grading standards!
Reflect on this case. Include: Discuss what you learned and what you might do differently. Also include in your reflection a discussion related to legal/ethical considerations (
demonstrate critical thinking beyond confidentiality and consent for treatment!), social determinates of health, health promotion and disease prevention taking into consideration patient factors (such as age, ethnic group, etc.), PMH, and other risk factors (e.g., socioeconomic, cultural background, etc.).
(The FOCUSED SOAP psychiatric evaluation is typically the
follow-up visit patient note. You will practice writing this type of note in this course. You will be focusing more on the symptoms from your differential diagnosis from the comprehensive psychiatric evaluation narrowing to your diagnostic impression. You will write up what symptoms are present and what symptoms are not present from illnesses to demonstrate you have indeed assessed for illnesses which could be impacting your patient. For ex.
How to write An Evidence Based Article?
The document provides guidelines for writing an evidence-based review article. It defines different types of review articles and outlines the key steps, which include: selecting a topic of clinical relevance; conducting a comprehensive literature search of sources like systematic reviews and clinical practice guidelines; evaluating the strength and validity of the evidence; and presenting the information in a standardized format covering introduction, methods, discussion, and references. The discussion section should provide an evidence-based analysis of a topic, acknowledge any controversies, and rate the level of evidence for key statements and recommendations.
[removed]NRNPPRAC 6665 & 6675 Focused SOAP Psychiatric Evaluati.docx
[removed]
NRNP/PRAC 6665 & 6675 Focused SOAP Psychiatric Evaluation Exemplar
INSTRUCTIONS ON HOW TO USE EXEMPLAR AND TEMPLATE—READ CAREFULLY
If you are struggling with the format or remembering what to include, follow the
Focused SOAP Note Evaluation Template
AND the Rubric
as your guide. It is also helpful to review the rubric in detail in order not to lose points unnecessarily because you missed something required. After reviewing full details of the rubric, you can use it as a guide.
In the
Subjective section, provide:
· Chief complaint
· History of present illness (HPI)
· Past psychiatric history
· Medication trials and current medications
· Psychotherapy or previous psychiatric diagnosis
· Pertinent substance use, family psychiatric/substance use, social, and medical history
· Allergies
· ROS
Read rating descriptions to see the grading standards!
In the
Objective section, provide:
· Physical exam documentation of systems pertinent to the chief complaint, HPI, and history
· Diagnostic results, including any labs, imaging, or other assessments needed to develop the differential diagnoses.
Read rating descriptions to see the grading standards!
In the
Assessment section, provide:
· Results of the mental status examination,
presented in paragraph form.
· At least three differentials with supporting evidence. List them from top priority to least priority. Compare the
DSM-5-TR diagnostic criteria for each differential diagnosis and explain what
DSM-5-TR criteria rules out the differential diagnosis to find an accurate diagnosis.
Explain the critical-thinking process that led you to the primary diagnosis you selected. Include pertinent positives and pertinent negatives for the specific patient case.
·
Read rating descriptions to see the grading standards!
Reflect on this case. Include: Discuss what you learned and what you might do differently. Also include in your reflection a discussion related to legal/ethical considerations (
demonstrate critical thinking beyond confidentiality and consent for treatment!), social determinates of health, health promotion and disease prevention taking into consideration patient factors (such as age, ethnic group, etc.), PMH, and other risk factors (e.g., socioeconomic, cultural background, etc.).
(The FOCUSED SOAP psychiatric evaluation is typically the
follow-up visit patient note. You will practice writing this type of note in this course. You will be focusing more on the symptoms from your differential diagnosis from the comprehensive psychiatric evaluation narrowing to your diagnostic impression. You will write up what symptoms are present and what symptoms are not present from illnesses to demonstrate you have indeed assessed for illnesses which could be impacting your patient. For .
CASE STUDYFemale, 15, separation anxiety disorder, Depression.docx
CASE STUDY:
Female, 15, separation anxiety disorder, Depression
The patient is a fifteen-year-old female teenager who presents to the clinic with her mother for her first assessment. Patient is being referral to the clinic by the school counselor due to low grades and poor school assistance. During the session, both the patient and the mother are neatly dressed. Her mother seems to be worried about her daughter. The patient said, "I worry a lot about my family members. I fear that one day my parents will be abducted or fatally injured. The worries and fears make me have difficulties concentrating on personal well-being and my studies in school." The mental assessment shows that the patient is depressed, and she refuses to leave the proximity of her mother. Her mother says that her daughter has been experiencing depression or anxiety attacks. The physical assessment shows that the patient has been experiencing physical aches and pains. She maintains good eye contact. Her mood is a little anxious. The symptoms conclude that the patient has separation anxiety disorder because the symptoms have progressed for the past six months. Treatments include antidepressants, group therapy, family therapy, dialectical behavioral therapy, and cognitive-behavioral therapy. A follow-up is to be done in two weeks.
Assignment 2: Focused SOAP Note and Patient Case Presentation
Psychiatric notes are a way to reflect on your practicum experiences and connect them to the didactic learning you gain from your NRNP courses. Focused SOAP notes, such as the ones required in this practicum course, are often used in clinical settings to document patient care.
For this Assignment, you will document information about a patient that you examined during the last three weeks, using the Focused SOAP Note Template provided. You will then use this note to develop and record a case presentation for this patient.
To Prepare
· Present the full complex case study. Include chief complaint; history of present illness; any pertinent past psychiatric, substance use, medical, social, family history; most recent mental status exam; current psychiatric diagnosis including differentials that were ruled out; and plan for treatment and management.
· Report normal diagnostic results as the name of the test and “normal” (rather than specific value). Abnormal results should be reported as a specific value.
· Specifically address the following for the patient, using your SOAP note as a guide:
·
Subjective: What details did the patient provide regarding their chief complaint and symptomology to derive your differential diagnosis? What is the duration and severity of their symptoms? How are their symptoms impacting their functioning in life?
·
Objective: What observations did you make during the psychiatric assessment?
·
Assessment: Discuss their mental status examination results. What were your differential diagnoses? Provide a minimum o.
NURS 6512 Assessment Tools and Diagnostic Tests.pdf
This document discusses three case studies of patients from diverse backgrounds presenting for physical exams. It prompts the reader to reflect on one case study and the cultural factors relevant to that patient's health. These include socioeconomic status, spirituality, lifestyle, and culture. The reader is asked to consider sensitive questions to build the patient's health history while being aware of their background. The goal is for healthcare providers to properly assess patients from a variety of populations.
History taking By Muhammad Arslan Yasin
History Taking
1.Name, age, sex, marital status, occupation, address (Demographics)
2. Presenting complaints
3. History of present illness
4. Systemic inquiry
5. Past history
6. Menstrual history
7. Treatment history
8. Family history
9. Personal and social history
10. Occupational history
Healthcare -- putting prevention into practice
This slidedeck is submitted by Zafar Hasan because one of the trends in medicine for the last 20 years isa focus on prevention and this deck is an outstanding practice primer.
Searching For The Evidence
- The document discusses evidence-based practice (EBP) and how to formulate clinical questions and search for evidence using databases and subject headings.
- The EBP process involves identifying a problem, developing a focused clinical question using PICO (population, intervention, comparison, outcome), searching relevant resources, critically appraising the evidence, and implementing in practice.
- Useful databases for finding evidence include CINAHL, MEDLINE, Cochrane Library. Subject headings and filters can help narrow search results.
You have been provided with case study in Week 4 that focused on.docx
You have been provided with case study in
Week 4
that focused on genitourinary .You will analyze and create a comprehensive plan of care for acute/chronic care, disease prevention, and health promotion for that patient and disorder. Your care plan should be based on current best practices and supported with citations from current literature, such as systematic reviews, published practice guidelines, standards of care from specialty organizations, and other research based resources. In addition, you will provide a detailed scientific rationale that justifies the inclusion of this evidence in your plan. Your paper should adhere to APA format for title page, headings, citations, and references. The paper should be no more than 3 pages typed excluding title page and references.
Criteria:
SOAP note
Evaluation of priority diagnosis
Facilitators and barriers to disorder management
Assignment 2 Grading Criteria
Maximum Points
Introduction
The submission included a general introduction to the priority diagnosis.
10
Subjective Data
The submission included the patient's interpretation of current medical problem. It included chief complaint, history of present illness, current medications and reason prescribed, past medical history, family history, and review of systems.
15
Objective Data
The submission included the measurements and observations obtained by the nurse practitioner. It included head to toe physical examination, laboratory and diagnostic testing results.
15
Assessment
The submission included at least three priority diagnoses. Each diagnosis was supported by documentation in subjective and objective notes and free of essential omissions. All diagnoses were documented using acceptable terminologies and current ICD-10 codes.
20
Plan of Care
Plan included diagnostic and therapeutic (pharmacologic and non-pharmacologic) management as well as education and counseling provided. The plan was supported by evidence/guidelines, and the follow-up plans were noted.
25
Evaluation of Priority Diagnosis
The plan chose the priority diagnosis for the pt and differentiated the disorder from normal development. Discussed the physical and psychological demands the disorder places on the patient and family and key concepts to discuss with them. Identified key interdisciplinary team personnel needed and how this team will provide care to achieve optimal disorder management and outcomes.
25
Facilitators and Barriers
The submission interpreted facilitators and barriers to optimal disorder management and outcomes and strategies to overcome the identified barriers.
20
Conclusion
The submission included what should be taken away from this assignment.
10
APA/Style/Format
The submission was free of grammatical, spelling, or punctuation errors. Citations and references were written in correct APA Style.
Utilized proper format with coversheet, header.
10
Total
150
.
Patient Assessment And Clinical Interviewing
The document provides guidance on common mistakes healthcare practitioners make in patient communication and assessment. It discusses the importance of greeting patients, understanding their concerns, asking open-ended questions, being attentive to verbal and non-verbal cues, avoiding judgements, and understanding cultural beliefs. It also outlines key information to collect during a patient assessment, including medical history, medications, allergies and social factors, and provides examples of documentation through a SOAP note.
Similar to Select a patient that you examined during the last four weeks. W.docx (20)
Develop a Focused SOAP including your differential diagnosis and.docx
Develop a Focused SOAP including your differential diagnosis and.docx
Presentation on medication history interview and soap notes
Presentation on medication history interview and soap notes
Diagnostic and Clinical Reasoning Paper AssignmentThe purpos
Diagnostic and Clinical Reasoning Paper AssignmentThe purpos
For this assignment, you are to complete aclinical case - narrat.docx
For this assignment, you are to complete aclinical case - narrat.docx
For this assignment, you are to complete aclinical case - narr.docx
For this assignment, you are to complete aclinical case - narr.docx
Evidence Based Practice and Finding the Information You Need
Evidence Based Practice and Finding the Information You Need
NRNPPRAC 6665 & 6675 Focused SOAP Psychiatric Evaluation Exemplar.docx
NRNPPRAC 6665 & 6675 Focused SOAP Psychiatric Evaluation Exemplar.docx
[removed]NRNPPRAC 6665 & 6675 Focused SOAP Psychiatric Evaluati.docx
[removed]NRNPPRAC 6665 & 6675 Focused SOAP Psychiatric Evaluati.docx
CASE STUDYFemale, 15, separation anxiety disorder, Depression.docx
CASE STUDYFemale, 15, separation anxiety disorder, Depression.docx
NURS 6512 Assessment Tools and Diagnostic Tests.pdf
NURS 6512 Assessment Tools and Diagnostic Tests.pdf
You have been provided with case study in Week 4 that focused on.docx
You have been provided with case study in Week 4 that focused on.docx
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Amy Simons is an aunt to my mum. Amy passed on May 31, 2020, while surrounded by all her family members after a long fight with colon cancer; she was 48.
On December 21, 1972, Amy Simons was born in Redbone, Alabama, to the late Hadley and Pauline Simons. According to the story I was told by my mum, Amy was a wonderful and selfless person. She was the third child of four after Christine Simons, Reuben Simons, and her older sister to Raphael. The majority of her childhood and teenage years were in Alabama before relocating to New York for her college education at New York University. During her term in the school, she met Joshua, whom they bore their first child Fredrick in 1990. She deferred for one year before resuming and completing her Human Resource Management degree. They got married in 1991, after which they relocated back to Huntsville, Alabama. They opened a bakery in 1993 and were well known by the local community. She gave birth to her second child Diana in 1995; during this period, she began complaining about stomach discomfort. The medical assessment resulted in her having an operation that corrected the issue. In 1999, the Simons family relocated out to Redstone, Alabama, where they resided until Joshua's premature death in 2016.
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Nazi Germany
Brenda Thomas
LaShuntae Jackson
The Rise of Nazi Germany
Hitler’s Expanding Axis
The United States’ Intervention
The Collapse of Nazi Germany
Key Points
The Rise of Nazi Germany
Hitler (Chancellor) January 30, 1933
Created A Secret Police Force
No Election
No Labor Unions
No Strikes
Cont. Hitler’ Expanding Axis
1. The Battle of Great Britain
German bombers attack Great Britain: The Blitz
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Hitler’s Expanding Axis
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A suite of forces and factors, including mutation, recombination,
selection, population history and gene duplication influence patterns
of intraspecific genetic variation. Distinguishing which factors have
shaped sequence variation across a genome requires extensive whole-
genome sequencing of multiple individuals, which has only recently
become tractable1. Most large-scale whole-genome resequencing
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species and, therefore, enhance understanding of adaptation.
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Nature VS Nurture
Research writing 310
Joi Tucker
Wilmington University
Nature VS Nurture
Abstract
Nature vs Nurture is one of the oldest arguments known to the Psychology genre. For those who do not know; simply put, the underlying question is, can behaviors be inherited? Initially, upon answering the question without any regard to the actual research and experiments done in this field a conclusion was drawn that Nature outweighs Nurture and that the behaviors of men are innate in that they are inherited genes that have influence over our behaviors. Upon further investigation and deeper insight, it is of my belief that the behaviors of men are based not solely on the behavior of their parents and their genetic makeup but also, by socioeconomic, traditional, educational, religious, and many other external factors. This paper will demonstrate the multiple schools of thought and their perspective on behaviorism, specifically when it comes to the argument of Nature vs Nurture. These perspectives will be used in order to justify the position that was previously stated, that the behaviors of men are influenced not only by their biology but also by their upbringing and multiple external factors.
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Within the world of biology, it is widely known that physical characteristics as well as one’s vulnerability to certain illnesses are because of one’s genetic makeup. It is of no surprise that one may share the color their mother’s eyes while inheriting their father’s diabetes. If you are a male, you may be prone to balding in your early 30’s just as your father did and women whose mother suffered from Breast Cancer have a higher likelihood of acquiring the same illness. Understanding how genetics works and now knowing how its functioning contributes to physical attributes as well as biological ailments, the question of whethe.
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- 1. Select a patient that you examined during the last four weeks. With this patient in mind, address the following in a SOAP Note: Subjective: What details did the patient provide regarding or her personal and medical history? Objective: What observations did you make during the physical assessment? Assessment: What were your differential diagnoses? Provide a minimum of three possible diagnoses. List them from highest priority to lowest priority. 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, including alternative therapies? Include pharmacologic and nonpharmacologic treatments, alternative therapies, and follow- up parameters, as well as a rationale for this treatment and management plan. Reflection notes: What would you do differently in a similar patient evaluation? (THE TOPIC HERE IS URINARY TRACT INFECTION (UTI) ) please use this format
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