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Reflections on developing an evaluation and communications strategy for the R...
A joint presentation given at the DECI-2 Workshop held in Cape Town on 3-5 May 2016. This presentation briefly outlines the ROER4D project and then briefly explores the evaluation and communications strategy. This presentation also gives feedback to the DECI-2 project on what worked and some sugestions for improvement in their mentoring process of the ROER4D project.
Credit insurance
Credit insurance is becoming increasingly important. Having the right payment terms with your customers is critical to your competitiveness and being able to grow your organisation with confidence. Ensuring that those terms of business are adhered to is not always in your control.
Without protection that your invoices will be paid, your business decisions are based on faith and past experience alone, which may not be the best grounds for ensuring business profitability.
According to the recent Atradius survey results for B2B payment practices, over 40% of invoices remain unpaid past due date.
This is where credit insurance and robust credit management policies can help. Credit insurance is as much about protection against bad debt as a facilitator for growth and maximising your profitability.
This short guide aims to help you understand how credit insurance can support your business, assess whether you really need it and give insight into why it is of growing importance.
Effct of Tungsten Inert Gas Welding & Shielded Metal Arc Welding Processes on...
Effct of Tungsten Inert Gas Welding & Shielded Metal Arc Welding Processes on...Suryaprakash Shanmugam
To determine the mechanical properties of Super duplex stainless steel (AISI 2507) during welding processes (Tungsten Inert Gas Welding & Shielded Metal Arc Welding).
To plot the thermal distribution curves in a simulation software using the data acquired with the help of sensors during the welding processes.For this homework assignment, you will continue coding for Reports 2.docx
For this homework assignment, you will continue coding for Reports 2-5, which are located on pages 182-184 of the Step-by-Step Workbook. Using Encoder Pro, create codes for information from Reports 2-5. Additionally, explain how you arrived at that code.
Report 2: Discharge Summary
Diagnoses include:
1. Chronic pelvic pain secondary to pelvic metastatic clear cell carcinoma of unknown primary location.
2. Vena Cava syndrome post placement of Hickman catheter.
3. Anemia due to chronic disease.
4. Hypertension.
HOSPITAL COURSE:
The patient is a 78 year old female whom we have been following in our clinic for hypertension and also chronic pudendal nerve pain. She had been recently diagnosed with pelvic metastatic clear cell carcinoma, which her primary location is unknown at this time. She will be discussing this further after the pathology reports are read. During her hospital stay a Hickman catheter was placed in order to have IV access for pain medication or future cancer therapy. She was also admitted for chronic pain. She did develop swelling of her arms and neck. She was brought to interventional radiology and she did have venography and the Hickman catheter was removed. Her swelling to her arms and neck have decreased greatly. She denies any shortness of breath. No choking sensation as previously noted. Her pain has been managed well with fentanyl patch at 175mcg. She has also been on IV heparin therapy for anticoagulation following the vena cava syndrome. Today, the patient has been having complaints of nausea. She did get some dexamethasone IV for her nausea, which did improve later this morning. Her blood pressure has been under good control. Her labs today include a WBC of 5.18, hemoglobin 7.8, hematocrit 23.7, protime 14.4, INR 1.5, PTT 39.6, BUN 6, sodium 139, potassium 4.2, and CO2 27.2.
DISCHARGE MEDICATIONS:
1. Will continue home medications.
2. Phenergan 12.5 1-2 tabs p.o. p.r.n. every 6 hours for nausea.
3. Lovenox 1 mg/kg subcutaneously every 24 hours.
4. Fentanyl patch 175 mcg to be changed every 3 days.
5. Epogen 40,000 units subcutaneously weekly at the Cancer Center.
REPORT 3. CLINIC CHART NOTE
HISTORY: This 16 year old female is seen today after falling off a curb and twisting her right ankle. She is normally a patient of Dr. Anderson, who is out of town this week. She states that she has pain surrounding the entire foot and ankle. Seems unable or unwilling to bear weight.(Problem focused history)
PHYSICAL EXAM: Ankle and foot examined. Foot is warm to the touch. Some swelling and bruising noted around the lateral aspect of the ankle. X-ray is negative for fracture. (problem focused examination)
IMPRESSION: Sprained right ankle. (MDM complexity straightforward)
PLAN: Elevation; ice to affected area. Weight bearing only as tolerated. Return for follow-up p.r.n.
REPORT 4: ADMIT INPATIENT
This is a 19 year old with a living-related donor kidney transplant as of last month and admitted to hospital fo ...
Yan 2Yichao YanKara WilliamsESL 10696 April 2019 Rough.docx
Yan 2
Yichao Yan
Kara Williams
ESL 1069
6 April 2019
Rough Draft Analysis of Argument Essay
In the article “What Else Can I Do to Get the School Supplies My Student Need?” the author discusses that, textbook still plays an important role in today’s class. There are so many debates about weather using online text book or physical textbook in school nowadays. The author as a college teacher claims that physical textbook helps her students have better understanding of knowledges. Also, she thinks physical textbook reduced the financial burden on students. However, online source or online textbook should have more benefit then the physical textbook.
First of all, the author claims that physical textbook could helps student read and understand better of new knowledges. The resources that teachers need for their teaching are so differently. It depended on student’s grade and their teaching style. Even people nowadays assume textbooks are outdated, inefficient and biased, author still think using textbook is very important for students to know about some academic basic information, which could help students master the course better.
APPENDIX I r Reports
DIAGNOSES include:
1. Chronic pelvic pain secondary to pelvic metastatic clear cell carcinoma
of unknown PrimarY location.
2. Yeta cava sy.rdromi post placement of Hickman catheter'
3. Anemia due to chronic disease.
4. Hypertension.
HOSPITAL COURSE: The patient is a 78-year-old female whom we have
been following in our clinic ior hypertension and also chronic pudendal
nerve pain. Shie had been recently biagnosed with pelvic me,tastatic clear
cell caicinoma, which her primaiy location is unknown at this time' She
will be discussing this further after the pathology reports are, read. During
her hospital stalia Hickman catheter was placed in order to have IV access
for pain medication or future cancer therapy. She was also admitted for
chronic pain. she did develop swelling of her arms and neck. She was
broughtio interventional radiology and she did have venography and the
Hickman catheter was removed. Her swelling to her arms and neck have
decreased greatly. She denies any shortness of breath. No choking sensation
as previouily noted. Her pain has been managed well with fentanyl patch at
175 mcg. She has also been on IV heparin therapy for anticoagulation
followitig the vena cava syndrome. Today, the patient hasbeen having
complaiits of nausea. She did get some dexamethasone IV for her nausea,
which did improve later this morning. Her blood plessure has been under
good control. Her labs today include a wBC of 5.18, hemoglobin 7.8,
f,ematocrit 23.7, protime 74.4,INR 1'5, PTT 39'6, BUN 6, sodium 139'
potassium 4.2, CO2 27.2.
DISCHARGE, PLANS:
1. IV heparin is discontinued. She will be switched ovel to Lovenox
r mg/kg subcutaneously daily. The patient will have Home Health to
help her set uP these iniections.
2. She will continue with the fentanyl patch 175 mcg for the pain..
SOAP NOTENameDateTime AgeSexSUBJECTIVECC .docx
SOAP NOTE
Name:
Date:
Time:
Age:
Sex:
SUBJECTIVE
CC:
Reason given by the patient for seeking medical care “in quotes”
HPI: Use OLDCART acronym
Describe the course of the patient’s illness, including when it began, character of symptoms, location where the symptoms began, aggravating or alleviating factors; pertinent positives and negatives, other related diseases, past illnesses, surgeries or past diagnostic testing related to present illness.
Medications: (list with reason for med ) write medicine the same way you write a Rx
PMH (list approximate year of Dx of the disease or when surgical procedure performed)
Allergies:
Medication Intolerances:
Chronic Illnesses/Major traumas
Hospitalizations/Surgeries
Family History (list immediate family, age, disease, and whether is dead or alive)
Does your mother, father or siblings have any medical or psychiatric illnesses? Anyone diagnosed with: lung disease, heart disease, htn, cancer, TB, DM, or kidney disease.
Social History
Education level, occupational history, current living situation/partner/marital status, substance use/abuse, ETOH, tobacco, marijuana. Safety status
ROS (Start each sentence with words such as “Denies, admits, complains, reports”, do not use the words “No, positive for, negative for”. Do NOT list physical exam findings here. If the body system not assess write “Non-Contributory”
General
Cardiovascular
Skin
Respiratory
Eyes
Gastrointestinal
Ears
Genitourinary/Gynecological
Nose/Mouth/Throat
Musculoskeletal
Breast
Neurological
Heme/Lymph/Endo
Psychiatric
OBJECTIVE- this is where you document physical exam findings, do NOT use the word NORMAL to document a finding, and instead explain what normal is. For example, the gait is not normal, the gait is steady. If the body part not assessed then type “Deferred”.
Weight BMI
Temp
BP
Height
Pulse
Resp
General Appearance
Skin
HEENT
Cardiovascular
Respiratory
Gastrointestinal
Breast
Genitourinary
Musculoskeletal
Neurological
Psychiatric
Lab Tests (lists any tests ordered and status of the test, if a rapid test was done at the office, list the results)
Special Tests (List any imaging study or special test ordered and status of the test, if the result is available, write the result)
Diagnosis
Differential Diagnoses with ICD 10 codes (these are Dx you considered, but then ruled out)
· 1-
· 2-
· 3-
Diagnosis with ICD 10 Code
CPT Code/Office visit code:
Plan/Therapeutics
· Plan:
· Further testing
· Medication
· Education
· Non-medication treatments
· Follow Up
· Referral
· When to seek emergency care
Evaluation of patient encounter
Document your level of interaction with the patient.
Weaknesses:
Strengths:
Reflection:
References:
Week 2: Respiratory Clinical Case
Patient Setting:
65 year old Caucasian female that was discharged from the hospital 10 weeks ago after a motor vehicle
accident presents to the clinic today. States she is having severe wheezing, shortness of b.
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Reflections on developing an evaluation and communications strategy for the R...
A joint presentation given at the DECI-2 Workshop held in Cape Town on 3-5 May 2016. This presentation briefly outlines the ROER4D project and then briefly explores the evaluation and communications strategy. This presentation also gives feedback to the DECI-2 project on what worked and some sugestions for improvement in their mentoring process of the ROER4D project.
Credit insurance
Credit insurance is becoming increasingly important. Having the right payment terms with your customers is critical to your competitiveness and being able to grow your organisation with confidence. Ensuring that those terms of business are adhered to is not always in your control.
Without protection that your invoices will be paid, your business decisions are based on faith and past experience alone, which may not be the best grounds for ensuring business profitability.
According to the recent Atradius survey results for B2B payment practices, over 40% of invoices remain unpaid past due date.
This is where credit insurance and robust credit management policies can help. Credit insurance is as much about protection against bad debt as a facilitator for growth and maximising your profitability.
This short guide aims to help you understand how credit insurance can support your business, assess whether you really need it and give insight into why it is of growing importance.
Effct of Tungsten Inert Gas Welding & Shielded Metal Arc Welding Processes on...
Effct of Tungsten Inert Gas Welding & Shielded Metal Arc Welding Processes on...Suryaprakash Shanmugam
To determine the mechanical properties of Super duplex stainless steel (AISI 2507) during welding processes (Tungsten Inert Gas Welding & Shielded Metal Arc Welding).
To plot the thermal distribution curves in a simulation software using the data acquired with the help of sensors during the welding processes.Viewers also liked (12)
Reflections on developing an evaluation and communications strategy for the R...
Reflections on developing an evaluation and communications strategy for the R...
Effct of Tungsten Inert Gas Welding & Shielded Metal Arc Welding Processes on...
Effct of Tungsten Inert Gas Welding & Shielded Metal Arc Welding Processes on...
Similar to SIGNOUT Pocket Card
For this homework assignment, you will continue coding for Reports 2.docx
For this homework assignment, you will continue coding for Reports 2-5, which are located on pages 182-184 of the Step-by-Step Workbook. Using Encoder Pro, create codes for information from Reports 2-5. Additionally, explain how you arrived at that code.
Report 2: Discharge Summary
Diagnoses include:
1. Chronic pelvic pain secondary to pelvic metastatic clear cell carcinoma of unknown primary location.
2. Vena Cava syndrome post placement of Hickman catheter.
3. Anemia due to chronic disease.
4. Hypertension.
HOSPITAL COURSE:
The patient is a 78 year old female whom we have been following in our clinic for hypertension and also chronic pudendal nerve pain. She had been recently diagnosed with pelvic metastatic clear cell carcinoma, which her primary location is unknown at this time. She will be discussing this further after the pathology reports are read. During her hospital stay a Hickman catheter was placed in order to have IV access for pain medication or future cancer therapy. She was also admitted for chronic pain. She did develop swelling of her arms and neck. She was brought to interventional radiology and she did have venography and the Hickman catheter was removed. Her swelling to her arms and neck have decreased greatly. She denies any shortness of breath. No choking sensation as previously noted. Her pain has been managed well with fentanyl patch at 175mcg. She has also been on IV heparin therapy for anticoagulation following the vena cava syndrome. Today, the patient has been having complaints of nausea. She did get some dexamethasone IV for her nausea, which did improve later this morning. Her blood pressure has been under good control. Her labs today include a WBC of 5.18, hemoglobin 7.8, hematocrit 23.7, protime 14.4, INR 1.5, PTT 39.6, BUN 6, sodium 139, potassium 4.2, and CO2 27.2.
DISCHARGE MEDICATIONS:
1. Will continue home medications.
2. Phenergan 12.5 1-2 tabs p.o. p.r.n. every 6 hours for nausea.
3. Lovenox 1 mg/kg subcutaneously every 24 hours.
4. Fentanyl patch 175 mcg to be changed every 3 days.
5. Epogen 40,000 units subcutaneously weekly at the Cancer Center.
REPORT 3. CLINIC CHART NOTE
HISTORY: This 16 year old female is seen today after falling off a curb and twisting her right ankle. She is normally a patient of Dr. Anderson, who is out of town this week. She states that she has pain surrounding the entire foot and ankle. Seems unable or unwilling to bear weight.(Problem focused history)
PHYSICAL EXAM: Ankle and foot examined. Foot is warm to the touch. Some swelling and bruising noted around the lateral aspect of the ankle. X-ray is negative for fracture. (problem focused examination)
IMPRESSION: Sprained right ankle. (MDM complexity straightforward)
PLAN: Elevation; ice to affected area. Weight bearing only as tolerated. Return for follow-up p.r.n.
REPORT 4: ADMIT INPATIENT
This is a 19 year old with a living-related donor kidney transplant as of last month and admitted to hospital fo ...
Yan 2Yichao YanKara WilliamsESL 10696 April 2019 Rough.docx
Yan 2
Yichao Yan
Kara Williams
ESL 1069
6 April 2019
Rough Draft Analysis of Argument Essay
In the article “What Else Can I Do to Get the School Supplies My Student Need?” the author discusses that, textbook still plays an important role in today’s class. There are so many debates about weather using online text book or physical textbook in school nowadays. The author as a college teacher claims that physical textbook helps her students have better understanding of knowledges. Also, she thinks physical textbook reduced the financial burden on students. However, online source or online textbook should have more benefit then the physical textbook.
First of all, the author claims that physical textbook could helps student read and understand better of new knowledges. The resources that teachers need for their teaching are so differently. It depended on student’s grade and their teaching style. Even people nowadays assume textbooks are outdated, inefficient and biased, author still think using textbook is very important for students to know about some academic basic information, which could help students master the course better.
APPENDIX I r Reports
DIAGNOSES include:
1. Chronic pelvic pain secondary to pelvic metastatic clear cell carcinoma
of unknown PrimarY location.
2. Yeta cava sy.rdromi post placement of Hickman catheter'
3. Anemia due to chronic disease.
4. Hypertension.
HOSPITAL COURSE: The patient is a 78-year-old female whom we have
been following in our clinic ior hypertension and also chronic pudendal
nerve pain. Shie had been recently biagnosed with pelvic me,tastatic clear
cell caicinoma, which her primaiy location is unknown at this time' She
will be discussing this further after the pathology reports are, read. During
her hospital stalia Hickman catheter was placed in order to have IV access
for pain medication or future cancer therapy. She was also admitted for
chronic pain. she did develop swelling of her arms and neck. She was
broughtio interventional radiology and she did have venography and the
Hickman catheter was removed. Her swelling to her arms and neck have
decreased greatly. She denies any shortness of breath. No choking sensation
as previouily noted. Her pain has been managed well with fentanyl patch at
175 mcg. She has also been on IV heparin therapy for anticoagulation
followitig the vena cava syndrome. Today, the patient hasbeen having
complaiits of nausea. She did get some dexamethasone IV for her nausea,
which did improve later this morning. Her blood plessure has been under
good control. Her labs today include a wBC of 5.18, hemoglobin 7.8,
f,ematocrit 23.7, protime 74.4,INR 1'5, PTT 39'6, BUN 6, sodium 139'
potassium 4.2, CO2 27.2.
DISCHARGE, PLANS:
1. IV heparin is discontinued. She will be switched ovel to Lovenox
r mg/kg subcutaneously daily. The patient will have Home Health to
help her set uP these iniections.
2. She will continue with the fentanyl patch 175 mcg for the pain..
SOAP NOTENameDateTime AgeSexSUBJECTIVECC .docx
SOAP NOTE
Name:
Date:
Time:
Age:
Sex:
SUBJECTIVE
CC:
Reason given by the patient for seeking medical care “in quotes”
HPI: Use OLDCART acronym
Describe the course of the patient’s illness, including when it began, character of symptoms, location where the symptoms began, aggravating or alleviating factors; pertinent positives and negatives, other related diseases, past illnesses, surgeries or past diagnostic testing related to present illness.
Medications: (list with reason for med ) write medicine the same way you write a Rx
PMH (list approximate year of Dx of the disease or when surgical procedure performed)
Allergies:
Medication Intolerances:
Chronic Illnesses/Major traumas
Hospitalizations/Surgeries
Family History (list immediate family, age, disease, and whether is dead or alive)
Does your mother, father or siblings have any medical or psychiatric illnesses? Anyone diagnosed with: lung disease, heart disease, htn, cancer, TB, DM, or kidney disease.
Social History
Education level, occupational history, current living situation/partner/marital status, substance use/abuse, ETOH, tobacco, marijuana. Safety status
ROS (Start each sentence with words such as “Denies, admits, complains, reports”, do not use the words “No, positive for, negative for”. Do NOT list physical exam findings here. If the body system not assess write “Non-Contributory”
General
Cardiovascular
Skin
Respiratory
Eyes
Gastrointestinal
Ears
Genitourinary/Gynecological
Nose/Mouth/Throat
Musculoskeletal
Breast
Neurological
Heme/Lymph/Endo
Psychiatric
OBJECTIVE- this is where you document physical exam findings, do NOT use the word NORMAL to document a finding, and instead explain what normal is. For example, the gait is not normal, the gait is steady. If the body part not assessed then type “Deferred”.
Weight BMI
Temp
BP
Height
Pulse
Resp
General Appearance
Skin
HEENT
Cardiovascular
Respiratory
Gastrointestinal
Breast
Genitourinary
Musculoskeletal
Neurological
Psychiatric
Lab Tests (lists any tests ordered and status of the test, if a rapid test was done at the office, list the results)
Special Tests (List any imaging study or special test ordered and status of the test, if the result is available, write the result)
Diagnosis
Differential Diagnoses with ICD 10 codes (these are Dx you considered, but then ruled out)
· 1-
· 2-
· 3-
Diagnosis with ICD 10 Code
CPT Code/Office visit code:
Plan/Therapeutics
· Plan:
· Further testing
· Medication
· Education
· Non-medication treatments
· Follow Up
· Referral
· When to seek emergency care
Evaluation of patient encounter
Document your level of interaction with the patient.
Weaknesses:
Strengths:
Reflection:
References:
Week 2: Respiratory Clinical Case
Patient Setting:
65 year old Caucasian female that was discharged from the hospital 10 weeks ago after a motor vehicle
accident presents to the clinic today. States she is having severe wheezing, shortness of b.
SOAP NOTE SAMPLE FORMAT FOR MRCName LPDate.docx
SOAP NOTE SAMPLE FORMAT FOR MRC
Name:
LP
Date:
Time:
1315
Age:
30
Sex:
F
SUBJECTIVE
CC:
“I am having vaginal itching and pain in my lower abdomen.”
HPI:
Pt is a 30y/o AA female, who is a new patient that has recently moved to Miami. She seeks treatment today after unsuccessful self-treatment of vaginal itching, burning upon urination, and lower abdominal pain. She is concerned for the presence of a vaginal or bladder infection, or an STD. Pt denies fever. She reports the itching and burning with urination has been present for 3 weeks, and the abdominal pain has been intermittent since months ago. Pt has tried OTC products for the itching, including Monistat and Vagisil. She denies any other urinary symptoms, including urgency or frequency. She describes the abdominal pain as either sharp or dull. The pain level goes as high as 8 out of 10 at times. 200mg of PO Advil PRN reduces the pain to a 7/10. Pt denies any aggravating factors for the pain. Pt reports that she did start her menstrual cycle this morning, but denies any other discharge other that light bleeding beginning today. Pt denies douching or the use of any vaginal irritants. She reports that she is in a stable sexual relationship, and denies any new sexual partners in the last 90 days. She denies any recent or historic known exposure to STDs. She reports the use of condoms with every coital experience, as well as this being her only form of contraceptive. She reports normal monthly menstrual cycles that last 3-4 days. She reports dysmenorrhea, which she also takes Advil for. She reports her last PAP smear was in 7/2016, was normal, and reports never having an abnormal PAP smear result. Pt denies any hx of pregnancies. Other medical hx includes GERD. She reports that she has an Rx for Protonix, but she does not take it every day. Her family hx includes the presence of DM and HTN.
Current Medications:
Protonix 40mg PO Daily for GERD
MTV OTC PO Daily
Advil 200mg OTC PO PRN for pain
PMHx:
Allergies:
NKA & NKDA
Medication Intolerances:
Denies
Chronic Illnesses/Major traumas
GERD
Hospitalizations/Surgeries
Denies
Family History
Father- DM & HTN; Mother- HTN; Older sister- DM & HTN; Maternal and paternal grandparents without known medical issues; 1 brother and 3 other sisters without known medical issues; No children.
Social History
Lives alone. Currently in a stable sexual relationship with one man. Works for DEFACS. Reports occasional alcohol use, but denies tobacco or illicit drug use.
ROS
General
Denies weight change, fatigue, fever, night sweats
Cardiovascular
Denies chest pain and edema. Reports rare palpitations that are relieved by drinking water
Skin
Denies any wounds, rashes, bruising, bleeding or skin discolorations, any changes in lesions
Respiratory
Denies cough. Reports dyspnea that accompanies the rare palpitati.
ADMISSION HISTORY AND PHYSICALPatient Name Jonathan Jones.docx
ADMISSION HISTORY AND PHYSICAL
Patient Name:
Jonathan Jones
MR#:
44579
Attending Physician:
Ajay Shah, M.D.
DOB:
12/24/89
Chief Complaint:
27 yo [
year old
] male presents with 2 days of worsening right lower quadrant belly pain, nausea, and vomiting.
History of Present Illness (HPI):
2 days prior to admission, the patient began complaining of diffuse belly pain that initially felt like indigestion. Over the course of the day, this pain grew progressively worse, localizing in the right lower quadrant. This pain became constant and dull and radiated to the back. The evening prior to admission the patient was awakened by pain and nausea. He drank some Alka-Seltzer and attempted to return to sleep, shortly after which he began vomiting nonbloody or bilious emesis. Shortly thereafter, the patient decided to come to the ED [
Emergency Department
].
The patient indicates he did have a fever but did not take his temperature. He denies chills, testicular pain, blood in the stool, or recent weight change. The patient’s last bowel movement was yesterday, with some small amounts of mucus but otherwise normal. He notes a history of irritable bowel syndrome. However, he states that this pain is different than the pain he has had in the past.
Past Medical History (PMH):
Irritable bowel syndrome, last exacerbation 6 months ago. The rest of the past medical history is unremarkable.
Past Surgical History (PSH):
Tonsillectomy and adenoidectomy in early childhood. Umbilical hernia repair at age 4.
Medications:
None.
Allergies:
NKDA
Social History:
The patient is employed as a computer programmer. He is married and has no children. He has a 10-year pack-history (in this case, 5 years, two packs a day) of smoking. He drinks alcohol rarely.
Family History:
Both parents are alive and well. One sister has a history of GERD.
Review of Systems:
12-point review of systems was performed and was negative except for those items noted in the HPI above.
Physical Examination
General:
The patient is an alert and oriented male appearing his stated age. He appears to be in moderate distress. Vital signs: blood pressure 132/78. Pulse 68 and regular. Temperature 38.56°C (101.4°F).
HEENT:
Normocephalic, atraumatic. Pupils were equal, round, and reactive to light. Ears clear. Throat normal.
Neck:
The neck is supple with no carotid bruits.
Lungs:
The lungs are clear to auscultation and percussion.
Heart:
RRR, no m/g/r.
Abdomen:
Nondistended. Bowel sounds are normal. There is rebound tenderness on the left side, with discomfort and guarding upon palpation in the right lower quadrant, and positive psoas sign [
pain on extension of right thigh with patient lying on left side
].
Extremities:
No clubbing, cyanosis, or edema, distal extremities warm and well perfused.
Laboratory Data:
Hemoglob.
SOAP NOTE SAMPLE FORMAT FOR MRCName LPDateTime 1315.docx
SOAP NOTE SAMPLE FORMAT FOR MRC
Name: LP
Date:
Time: 1315
Age: 30
Sex: F
SUBJECTIVE
CC:
“I am having vaginal itching and pain in my lower abdomen.”
HPI:
Pt is a 30y/o AA female, who is a new patient that has recently moved to Miami. She seeks treatment today after unsuccessful self-treatment of vaginal itching, burning upon urination, and lower abdominal pain. She is concerned for the presence of a vaginal or bladder infection, or an STD. Pt denies fever. She reports the itching and burning with urination has been present for 3 weeks, and the abdominal pain has been intermittent since months ago. Pt has tried OTC products for the itching, including Monistat and Vagisil. She denies any other urinary symptoms, including urgency or frequency. She describes the abdominal pain as either sharp or dull. The pain level goes as high as 8 out of 10 at times. 200mg of PO Advil PRN reduces the pain to a 7/10. Pt denies any aggravating factors for the pain. Pt reports that she did start her menstrual cycle this morning, but denies any other discharge other that light bleeding beginning today. Pt denies douching or the use of any vaginal irritants. She reports that she is in a stable sexual relationship, and denies any new sexual partners in the last 90 days. She denies any recent or historic known exposure to STDs. She reports the use of condoms with every coital experience, as well as this being her only form of contraceptive. She reports normal monthly menstrual cycles that last 3-4 days. She reports dysmenorrhea, which she also takes Advil for. She reports her last PAP smear was in 7/2016, was normal, and reports never having an abnormal PAP smear result. Pt denies any hx of pregnancies. Other medical hx includes GERD. She reports that she has an Rx for Protonix, but she does not take it every day. Her family hx includes the presence of DM and HTN.
Current Medications:
Protonix 40mg PO Daily for GERD
MTV OTC PO Daily
Advil 200mg OTC PO PRN for pain
PMHx:
Allergies:
NKA & NKDA
Medication Intolerances:
Denies
Chronic Illnesses/Major traumas
GERD
Hospitalizations/Surgeries
Denies
Family History
Father- DM & HTN; Mother- HTN; Older sister- DM & HTN; Maternal and paternal grandparents without known medical issues; 1 brother and 3 other sisters without known medical issues; No children.
Social History
Lives alone. Currently in a stable sexual relationship with one man. Works for DEFACS. Reports occasional alcohol use, but denies tobacco or illicit drug use.
ROS
General
Denies weight change, fatigue, fever, night sweats
Cardiovascular
Denies chest pain and edema. Reports rare palpitations that are relieved by drinking water
Skin
Denies any wounds, rashes, bruising, bleeding or skin discolorations, any changes in lesions
Respiratory
Denies cough. Reports dyspnea that accompanies the rare palpitations and is also relieved by drinking water
Eyes
Denies corrective lenses, blurring, visual changes of an.
CASE PRESENTATION : PYREXIA OF UNKNOWN ORIGIN / Hemophagocytic lymphohistioc...
CASE PRESENTATION : PYREXIA OF UNKNOWN ORIGIN / Hemophagocytic lymphohistioc...Dr. Darayus P. Gazder
PYREXIA OF UNKNOWN ORIGIN / Hemophagocytic lymphohistiocytosis / CASE PRESENTATION
Soap Note 2 Chronic ConditionsSoap Note Chronic Conditions (
Soap Note 2 Chronic Conditions
Soap Note Chronic Conditions (15 Points)
Pick any Chronic Disease from Weeks 6-10
Soap notes will be uploaded to Moodle and put through TURN-It-In (anti-Plagiarism program)
Follow the MRU Soap Note Rubric as a guide
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SOAP NOTE SAMPLE FORMAT FOR MRC
Name:
LP
Date:
Time:
1315
Age:
30
Sex:
F
SUBJECTIVE
CC:
“I am having vaginal itching and pain in my lower abdomen.”
HPI:
Pt is a 30y/o AA female, who is a new patient that has recently moved to Miami. She seeks treatment today after unsuccessful self-treatment of vaginal itching, burning upon urination, and lower abdominal pain. She is concerned for the presence of a vaginal or bladder infection, or an STD. Pt denies fever. She reports the itching and burning with urination has been present for 3 weeks, and the abdominal pain has been intermittent since months ago. Pt has tried OTC products for the itching, including Monistat and Vagisil. She denies any other urinary symptoms, including urgency or frequency. She describes the abdominal pain as either sharp or dull. The pain level goes as high as 8 out of 10 at times. 200mg of PO Advil PRN reduces the pain to a 7/10. Pt denies any aggravating factors for the pain. Pt reports that she did start her menstrual cycle this morning, but denies any other discharge other that light bleeding beginning today. Pt denies douching or the use of any vaginal irritants. She reports that she is in a stable sexual relationship, and denies any new sexual partners in the last 90 days. She denies any recent or historic known exposure to STDs. She reports the use of condoms with every coital experience, as well as this being her only form of contraceptive. She reports normal monthly menstrual cycles that last 3-4 days. She reports dysmenorrhea, which she also takes Advil for. She reports her last PAP smear was in 7/2016, was normal, and reports never having an abnormal PAP smear result. Pt denies any hx of pregnancies. Other medical hx includes GERD. She reports that she has an Rx for Protonix, but she does not take it every day. Her family hx includes the presence of DM and HTN.
Current Medications:
Protonix 40mg PO Daily for GERD
MTV OTC PO Daily
Advil 200mg OTC PO PRN for pain
PMHx:
Allergies:
NKA & NKDA
Medication Intolerances:
Denies
Chronic Illnesses/Major traumas
GERD
Hospitalizations/Surgeries
Denies
Family History
Father- DM & HTN; Mother- HTN; Older sister- DM & HTN; Maternal and paternal grandparents without known medical issues; 1 brother and 3 other sisters without known med ...
Immunologic Diseases andDisorders• Guillain-BarréSyndrome•.docx
Immunologic Diseases and
Disorders
• Guillain-Barré
Syndrome
• HIV/AIDS
• Hodgkin Lymphoma
• Leukemia
• Lupus
• Multiple Myeloma
• Multiple Sclerosis
• Scleroderma
Diseases and Disorders of the
Integumentary System
• Acne
• Burns
• Dermatitis
• Impetigo
• Lyme Disease
• Melanoma
• Methicillin-Resistant
Staphylococcus Aureus
(MRSA)
• Pediculosis (Lice)
• Psoriasis
• Tinea (Capitis, Corporis,
Cruris, Pedis)
• Scabies
• Stevens-Johnson
Syndrome
Diseases and disorders of the
Circulatory System:
• Acute Coronary
Syndrome (ACS)
• Anemia
• Aneurysm of the
Abdominal Aorta (Triple
A)
• Atrial Fibrillation & Atrial
Flutter
• Carotid Stenosis
• Deep Vein Thrombosis
(DVT)
• Endocarditis
• Heart Failure
• Hemophilia
• Heparin-Induced
Thrombocytopenia
• Hypercholesterolemia
• Hypertension
• Mitral Valve Prolapse,
Regurgitation, Stenosis
• Peripheral Arterial
Disease
• Raynaud Phenomenon
• Rhabdomyolysis
• Rocky Mountain Spotted
Fever
Respiratory System
• Asthma
• Atelectasis
• Basal/Squamous Cell
Carcinoma
• Bronchitis
• Chronic Obstructive
Pulmonary Disease and
Emphysema
• Cystic Fibrosis
• Influenza
• Legionnaires' Disease
• Sleep Apnea,
Obstructive
• Pleural Effusion
Pneumonia
• Pulmonary Emboli
• Sarcoidosis
• Tuberculosis (TB)
SOAP NOTE SAMPLE FORMAT FOR MRC
Name: LP
Date:
Time: 1315
Age: 30
Sex: F
SUBJECTIVE
CC:
“I am having vaginal itching and pain in my lower abdomen.”
HPI:
Pt is a 30y/o AA female, who is a new patient that has recently moved to Miami. She seeks treatment today after unsuccessful self-treatment of vaginal itching, burning upon urination, and lower abdominal pain. She is concerned for the presence of a vaginal or bladder infection, or an STD. Pt denies fever. She reports the itching and burning with urination has been present for 3 weeks, and the abdominal pain has been intermittent since months ago. Pt has tried OTC products for the itching, including Monistat and Vagisil. She denies any other urinary symptoms, including urgency or frequency. She describes the abdominal pain as either sharp or dull. The pain level goes as high as 8 out of 10 at times. 200mg of PO Advil PRN reduces the pain to a 7/10. Pt denies any aggravating factors for the pain. Pt reports that she did start her menstrual cycle this morning, but denies any other discharge other that light bleeding beginning today. Pt denies douching or the use of any vaginal irritants. She reports that she is in a stable sexual relationship, and denies any new sexual partners in the last 90 days. She denies any recent or historic known exposure to STDs. She reports the use of condoms with every coital experience, as well as this being her only form of contraceptive. She reports normal monthly menstrual cycles that last 3-4 days. She reports dysmenorrhea, which she also takes Advil for. She reports her last PAP smear was in 7/2016, was normal, and reports never having an abnormal PAP smear result. Pt denies any hx of pregnancies. Other medical hx inc ...
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Title: Sense of Smell
Presenter: Dr. Faiza, Assistant Professor of Physiology
Qualifications:
MBBS (Best Graduate, AIMC Lahore)
FCPS Physiology
ICMT, CHPE, DHPE (STMU)
MPH (GC University, Faisalabad)
MBA (Virtual University of Pakistan)
Learning Objectives:
Describe the primary categories of smells and the concept of odor blindness.
Explain the structure and location of the olfactory membrane and mucosa, including the types and roles of cells involved in olfaction.
Describe the pathway and mechanisms of olfactory signal transmission from the olfactory receptors to the brain.
Illustrate the biochemical cascade triggered by odorant binding to olfactory receptors, including the role of G-proteins and second messengers in generating an action potential.
Identify different types of olfactory disorders such as anosmia, hyposmia, hyperosmia, and dysosmia, including their potential causes.
Key Topics:
Olfactory Genes:
3% of the human genome accounts for olfactory genes.
400 genes for odorant receptors.
Olfactory Membrane:
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Laterally: Folds over the superior turbinate and upper surface of the middle turbinate.
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Olfactory Mucosa:
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SIGNOUT Pocket Card
- 1. “SIGNOUT?” VERBAL SIGN-OUT (Horwitz, et al. 2007) Sick or OK, this is our sickest patient, and he’s S DNR? full code. Identifying Mr. Jones is a 77-year-old gentleman I data (one with a right middle lobe pneumonia. liner) General He came in a week ago hypoxic and G hospital hypotensive but improved rapidly with course IV levofloxacin. Today he spiked to 39.5°C and white count bumped from 8 to 14. Portable New events chest x-ray was improved from N of day admission, we sent blood and urine cultures. U/A was negative but his IV site looked red so we started vanco. Overall Right now he is satting 98% on 2 L NC O health status and is afebrile. If he becomes persistently febrile or Upcoming starts to drops his pressures start possibilities normal saline at 125 cc/h and have a U with plan low threshold for calling the ICU to and take a look at him because possible rationale sepsis. I’d like you to look in on him around To Do midnight and make sure his vitals and overnight T exam are unchanged. I don’t expect with plan, any blood culture results back tonight rationale so there is no need to follow those up. Any ? Any questions? questions?
- 2. ANTICipate for Written Sign-out (Vidyarthi, et al. 2006) Administrative Data □ Patient name, age, gender □ Medical record number □ Room number □ Admission date □ Primary inpatient medical team, primary care physician □ Family contact information New Information (Clinical Update) □ Chief complaint, brief HPI, and diagnosis (or differential diagnosis) □ Updated list of medications with doses, updated allergies □ Updated, brief assessment by system/problem, with dates □ Current “baseline” status (e.g., mental status, cardiopulmonary, vital signs, especially if abnormal but stable) □ Recent procedures and significant events Tasks (What needs to be done) □ Prepare cross-coverage (e.g., patient consent for blood transfusion) □ Warn of incoming information (e.g., study results, consultant recommendations), and what action, if any, needs to be taken that night Illness □ Is the patient sick? Contingency Planning / Code Status □ What may go wrong and what to do about it □ Using if/then statements □ What has or hasn’t worked before (e.g., responds to 40mg IV furosemide) □ Difficult family or psychosocial situations □ Code status, especially recent changes or family discussions