SOAP NOTE SAMPLE FORMAT FOR MRC
Name: LP
Date:
Time: 1315
Age: 30
Sex: F
SUBJECTIVE
CC:
“I am having vaginal itching and pain in my lower abdomen.”
HPI:
Pt is a 30y/o AA female, who is a new patient that has recently moved to Miami. She seeks treatment today after unsuccessful self-treatment of vaginal itching, burning upon urination, and lower abdominal pain. She is concerned for the presence of a vaginal or bladder infection, or an STD. Pt denies fever. She reports the itching and burning with urination has been present for 3 weeks, and the abdominal pain has been intermittent since months ago. Pt has tried OTC products for the itching, including Monistat and Vagisil. She denies any other urinary symptoms, including urgency or frequency. She describes the abdominal pain as either sharp or dull. The pain level goes as high as 8 out of 10 at times. 200mg of PO Advil PRN reduces the pain to a 7/10. Pt denies any aggravating factors for the pain. Pt reports that she did start her menstrual cycle this morning, but denies any other discharge other that light bleeding beginning today. Pt denies douching or the use of any vaginal irritants. She reports that she is in a stable sexual relationship, and denies any new sexual partners in the last 90 days. She denies any recent or historic known exposure to STDs. She reports the use of condoms with every coital experience, as well as this being her only form of contraceptive. She reports normal monthly menstrual cycles that last 3-4 days. She reports dysmenorrhea, which she also takes Advil for. She reports her last PAP smear was in 7/2016, was normal, and reports never having an abnormal PAP smear result. Pt denies any hx of pregnancies. Other medical hx includes GERD. She reports that she has an Rx for Protonix, but she does not take it every day. Her family hx includes the presence of DM and HTN.
Current Medications:
Protonix 40mg PO Daily for GERD
MTV OTC PO Daily
Advil 200mg OTC PO PRN for pain
PMHx:
Allergies:
NKA & NKDA
Medication Intolerances:
Denies
Chronic Illnesses/Major traumas
GERD
Hospitalizations/Surgeries
Denies
Family History
Father- DM & HTN; Mother- HTN; Older sister- DM & HTN; Maternal and paternal grandparents without known medical issues; 1 brother and 3 other sisters without known medical issues; No children.
Social History
Lives alone. Currently in a stable sexual relationship with one man. Works for DEFACS. Reports occasional alcohol use, but denies tobacco or illicit drug use.
ROS
General
Denies weight change, fatigue, fever, night sweats
Cardiovascular
Denies chest pain and edema. Reports rare palpitations that are relieved by drinking water
Skin
Denies any wounds, rashes, bruising, bleeding or skin discolorations, any changes in lesions
Respiratory
Denies cough. Reports dyspnea that accompanies the rare palpitations and is also relieved by drinking water
Eyes
Denies corrective lenses, blurring, visual changes of an.
SOAP NOTE
Name: J.D.
Date: 03/26/2020
Time: 2:00 pm
Age: 25 y/o
Sex: F
SUBJECTIVE
CC:
” I have a lot of pain on my left side, in my lower belly”
HPI: J.D. is a 25-year-old white female that came to the office today complaining of pain in her lower abdomen. The patient has always had painful cramps with her periods but this time it is much worse being described as a 6 out of 10 and lasting up to 5 hours. The pain started 2 days ago. The pain is described as more painful cramps. It is debilitating and prevents the patient from performing most daily activities. It is localized in the lower abdominal area, and sometimes radiates down her legs, and to her lower back. The patient uses hot compresses to relieve the pain as Tylenol does not work. The patient also states that she has been feeling nauseous ever since the pain started. She also urinates more frequently and pain on urination. Denies fever, vomiting, or chills.
Medications:
2 Tylenol as needed for her pain
PMH (include-immunization status including Gardisil, GTPLA).
Current or past illnesses: No current or past illnesses
Immunizations: All vaccines updated including flu vaccine and Gardasil.
Allergies: NKDA
Medication Intolerances: None.
Chronic Illnesses/Major traumas: None.
Hospitalizations/Surgeries (include delivery of pregnancies here)
No hospitalizations.
G0P0
Family History
Mother: 49 years old, no significant health problems
Maternal Side: No significant health problems
Father: 50 years old, hypertensive
Paternal Side: no significant health problems
Social History
Patient works full-time as a research assistant at a local university. A full-time student seeking a master’s degree in biochemistry at a local university. Married. Sexually active only with husband. Always uses male condoms as contraceptive device. Does not use recreational drugs, tobacco, or electronic cigarettes. Devout follower of Christianity. Denomination: catholic.
ROS
General Patient denies fever or chills, no weight changes.
Cardiovascular Denies chest pain, or discomfort. Denies palpitations, dyspnea, or orthopnea.
Skin: Denies presences of moles, rash, or itching.
Respiratory: Denies dyspnea, cough, hemoptysis, or pleuritic pains.
Eyes Denies problems or changes in her vision; denies double or blurred vision.
Gastrointestinal Positive for nausea.Denies hemorrhoids, constipation, or diarrhea. No variation in bowel habits. Denies vomiting.
Ears Denies difficulty or changes in his hearing. Denies tinnitus, or discharges.
Genitourinary/Gynecological Menarche 11 years old. Regular menstrual periods starting around the 3rd week of every month. LMP: 03.
SOAP NOTE SAMPLE FORMAT FOR MRCName LPDateTime 1315.docxrosemariebrayshaw
SOAP NOTE SAMPLE FORMAT FOR MRC
Name: LP
Date:
Time: 1315
Age: 30
Sex: F
SUBJECTIVE
CC:
“I am having vaginal itching and pain in my lower abdomen.”
HPI:
Pt is a 30y/o AA female, who is a new patient that has recently moved to Miami. She seeks treatment today after unsuccessful self-treatment of vaginal itching, burning upon urination, and lower abdominal pain. She is concerned for the presence of a vaginal or bladder infection, or an STD. Pt denies fever. She reports the itching and burning with urination has been present for 3 weeks, and the abdominal pain has been intermittent since months ago. Pt has tried OTC products for the itching, including Monistat and Vagisil. She denies any other urinary symptoms, including urgency or frequency. She describes the abdominal pain as either sharp or dull. The pain level goes as high as 8 out of 10 at times. 200mg of PO Advil PRN reduces the pain to a 7/10. Pt denies any aggravating factors for the pain. Pt reports that she did start her menstrual cycle this morning, but denies any other discharge other that light bleeding beginning today. Pt denies douching or the use of any vaginal irritants. She reports that she is in a stable sexual relationship, and denies any new sexual partners in the last 90 days. She denies any recent or historic known exposure to STDs. She reports the use of condoms with every coital experience, as well as this being her only form of contraceptive. She reports normal monthly menstrual cycles that last 3-4 days. She reports dysmenorrhea, which she also takes Advil for. She reports her last PAP smear was in 7/2016, was normal, and reports never having an abnormal PAP smear result. Pt denies any hx of pregnancies. Other medical hx includes GERD. She reports that she has an Rx for Protonix, but she does not take it every day. Her family hx includes the presence of DM and HTN.
Current Medications:
Protonix 40mg PO Daily for GERD
MTV OTC PO Daily
Advil 200mg OTC PO PRN for pain
PMHx:
Allergies:
NKA & NKDA
Medication Intolerances:
Denies
Chronic Illnesses/Major traumas
GERD
Hospitalizations/Surgeries
Denies
Family History
Father- DM & HTN; Mother- HTN; Older sister- DM & HTN; Maternal and paternal grandparents without known medical issues; 1 brother and 3 other sisters without known medical issues; No children.
Social History
Lives alone. Currently in a stable sexual relationship with one man. Works for DEFACS. Reports occasional alcohol use, but denies tobacco or illicit drug use.
ROS
General
Denies weight change, fatigue, fever, night sweats
Cardiovascular
Denies chest pain and edema. Reports rare palpitations that are relieved by drinking water
Skin
Denies any wounds, rashes, bruising, bleeding or skin discolorations, any changes in lesions
Respiratory
Denies cough. Reports dyspnea that accompanies the rare palpitations and is also relieved by drinking water
Eyes
Denies corrective lenses, blurring, visual changes of an.
SOAP NOTE SAMPLE FORMAT FOR MRCName LPDate.docxpbilly1
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.
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
Turn it in Score must be less than 50% or will not be accepted for credit, must be your own work and in your own words. You can resubmit, Final submission will be accepted if less than 50%. Copy paste from websites or textbooks will not be accepted or tolerated. Please see College Handbook with reference to Academic Misconduct Statement
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 ...
Sample Soap Note:
Soap Note # Main Diagnosis ( Exp: H&P Note #3 DX: Hypertension)
Student Name
Miami Regional University
Date of Encounter:
Preceptor/Clinical Site:
Clinical Instructor: Dr. Rafael Camejo
Soap Note #
Main Diagnosis
( Exp: Soap Note #3 DX: Hypertension)
PATIENT INFORMATION
Name
: Mr. DT
Age
: 68-year-old
Gender at Birth:
Male
Gender Identity
: Male
Source
: Patient
Allergies
: PCN, Iodine
Current Medications:
· Atorvastatin tab 20 mg, 1-tab PO at bedtime
· ASA 81mg po daily
· Multi-Vitamin Centrum Silver
PMH:
Hypercholesterolemia
Immunizations:
Influenza last 2018-year, tetanus, and hepatitis A and B 4 years ago.
Preventive Care
: Coloscopy 5 years ago (Negative)
Surgical History
: Appendectomy 47 years ago.
Family History
: Father- died 81 does not report information
Mother-alive, 88 years old, Diabetes Mellitus, HTN
Daughter-alive, 34 years old, healthy
Social History
: No smoking history or illicit drug use, occasional alcoholic beverage consumption on social celebrations. Retired, widow, he lives alone.
Sexual Orientation
: Straight
Nutrition History
: Diets off and on, Does not each seafood
Subjective Data:
Chief Complaint
: “headaches” that started two weeks ago
Symptom analysis/HPI:
The patient is 65 years old male who complaining of episodes of headaches and on 3 different occasions blood pressure was measured, which was high (159/100, 158/98 and 160/100 respectively). Patient noticed the problem started two weeks ago and sometimes it is accompanied by dizziness. He states that he has been under stress in his workplace for the last month. Patient denies chest pain, palpitation, shortness of breath, nausea or vomiting.
Review of Systems (ROS)
CONSTITUTIONAL
: Denies fever or chills. Denies weakness or weight loss.
NEUROLOGIC
: Headache and dizziness as describe above. Denies changes in LOC. Denies history of tremors or seizures.
HEENT
: HEAD: Denies any head injury, or change in LOC. Eyes: Denies any changes in vision, diplopia or blurred vision. Ear: Denies pain in the ears. Denies loss of hearing or drainage. Nose: Denies nasal drainage, congestion. THROAT: Denies throat or neck pain, hoarseness, difficulty swallowing.
RESPIRATORY
: Patient denies shortness of breath, cough or hemoptysis.
CARDIOVASCULAR
: No chest pain, tachycardia. No orthopnea or paroxysmal nocturnal
dyspnea.
GASTROINTESTINAL
: Denies abdominal pain or discomfort. Denies flatulence, nausea, vomiting or
diarrhea.
GENITOURINARY
: Denies hematuria, dysuria or change in urinary frequency. Denies difficulty starting/stopping stream of urine or incontinence.
MUSCULOSKELETAL
: Denies falls or pain. Denies hearing a clicking or snapping sound.
SKIN
: No change of coloration such as cyanosis or jaundice, no rashes or pruritus.
Objective Data:
VITAL SIGNS:
Temperature: 98.5 °F, Pulse: 87, BP: 159/92 mmhg, RR 20, PO2-98% on room air, Ht- 6’4”, Wt 200 lb, BMI 25. Report pain 2/10.
GENERAL APPREARANCE
.
SOAP NOTE
Name: J.D.
Date: 03/26/2020
Time: 2:00 pm
Age: 25 y/o
Sex: F
SUBJECTIVE
CC:
” I have a lot of pain on my left side, in my lower belly”
HPI: J.D. is a 25-year-old white female that came to the office today complaining of pain in her lower abdomen. The patient has always had painful cramps with her periods but this time it is much worse being described as a 6 out of 10 and lasting up to 5 hours. The pain started 2 days ago. The pain is described as more painful cramps. It is debilitating and prevents the patient from performing most daily activities. It is localized in the lower abdominal area, and sometimes radiates down her legs, and to her lower back. The patient uses hot compresses to relieve the pain as Tylenol does not work. The patient also states that she has been feeling nauseous ever since the pain started. She also urinates more frequently and pain on urination. Denies fever, vomiting, or chills.
Medications:
2 Tylenol as needed for her pain
PMH (include-immunization status including Gardisil, GTPLA).
Current or past illnesses: No current or past illnesses
Immunizations: All vaccines updated including flu vaccine and Gardasil.
Allergies: NKDA
Medication Intolerances: None.
Chronic Illnesses/Major traumas: None.
Hospitalizations/Surgeries (include delivery of pregnancies here)
No hospitalizations.
G0P0
Family History
Mother: 49 years old, no significant health problems
Maternal Side: No significant health problems
Father: 50 years old, hypertensive
Paternal Side: no significant health problems
Social History
Patient works full-time as a research assistant at a local university. A full-time student seeking a master’s degree in biochemistry at a local university. Married. Sexually active only with husband. Always uses male condoms as contraceptive device. Does not use recreational drugs, tobacco, or electronic cigarettes. Devout follower of Christianity. Denomination: catholic.
ROS
General Patient denies fever or chills, no weight changes.
Cardiovascular Denies chest pain, or discomfort. Denies palpitations, dyspnea, or orthopnea.
Skin: Denies presences of moles, rash, or itching.
Respiratory: Denies dyspnea, cough, hemoptysis, or pleuritic pains.
Eyes Denies problems or changes in her vision; denies double or blurred vision.
Gastrointestinal Positive for nausea.Denies hemorrhoids, constipation, or diarrhea. No variation in bowel habits. Denies vomiting.
Ears Denies difficulty or changes in his hearing. Denies tinnitus, or discharges.
Genitourinary/Gynecological Menarche 11 years old. Regular menstrual periods starting around the 3rd week of every month. LMP: 03.
SOAP NOTE SAMPLE FORMAT FOR MRCName LPDateTime 1315.docxrosemariebrayshaw
SOAP NOTE SAMPLE FORMAT FOR MRC
Name: LP
Date:
Time: 1315
Age: 30
Sex: F
SUBJECTIVE
CC:
“I am having vaginal itching and pain in my lower abdomen.”
HPI:
Pt is a 30y/o AA female, who is a new patient that has recently moved to Miami. She seeks treatment today after unsuccessful self-treatment of vaginal itching, burning upon urination, and lower abdominal pain. She is concerned for the presence of a vaginal or bladder infection, or an STD. Pt denies fever. She reports the itching and burning with urination has been present for 3 weeks, and the abdominal pain has been intermittent since months ago. Pt has tried OTC products for the itching, including Monistat and Vagisil. She denies any other urinary symptoms, including urgency or frequency. She describes the abdominal pain as either sharp or dull. The pain level goes as high as 8 out of 10 at times. 200mg of PO Advil PRN reduces the pain to a 7/10. Pt denies any aggravating factors for the pain. Pt reports that she did start her menstrual cycle this morning, but denies any other discharge other that light bleeding beginning today. Pt denies douching or the use of any vaginal irritants. She reports that she is in a stable sexual relationship, and denies any new sexual partners in the last 90 days. She denies any recent or historic known exposure to STDs. She reports the use of condoms with every coital experience, as well as this being her only form of contraceptive. She reports normal monthly menstrual cycles that last 3-4 days. She reports dysmenorrhea, which she also takes Advil for. She reports her last PAP smear was in 7/2016, was normal, and reports never having an abnormal PAP smear result. Pt denies any hx of pregnancies. Other medical hx includes GERD. She reports that she has an Rx for Protonix, but she does not take it every day. Her family hx includes the presence of DM and HTN.
Current Medications:
Protonix 40mg PO Daily for GERD
MTV OTC PO Daily
Advil 200mg OTC PO PRN for pain
PMHx:
Allergies:
NKA & NKDA
Medication Intolerances:
Denies
Chronic Illnesses/Major traumas
GERD
Hospitalizations/Surgeries
Denies
Family History
Father- DM & HTN; Mother- HTN; Older sister- DM & HTN; Maternal and paternal grandparents without known medical issues; 1 brother and 3 other sisters without known medical issues; No children.
Social History
Lives alone. Currently in a stable sexual relationship with one man. Works for DEFACS. Reports occasional alcohol use, but denies tobacco or illicit drug use.
ROS
General
Denies weight change, fatigue, fever, night sweats
Cardiovascular
Denies chest pain and edema. Reports rare palpitations that are relieved by drinking water
Skin
Denies any wounds, rashes, bruising, bleeding or skin discolorations, any changes in lesions
Respiratory
Denies cough. Reports dyspnea that accompanies the rare palpitations and is also relieved by drinking water
Eyes
Denies corrective lenses, blurring, visual changes of an.
SOAP NOTE SAMPLE FORMAT FOR MRCName LPDate.docxpbilly1
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.
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
Turn it in Score must be less than 50% or will not be accepted for credit, must be your own work and in your own words. You can resubmit, Final submission will be accepted if less than 50%. Copy paste from websites or textbooks will not be accepted or tolerated. Please see College Handbook with reference to Academic Misconduct Statement
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 ...
Sample Soap Note:
Soap Note # Main Diagnosis ( Exp: H&P Note #3 DX: Hypertension)
Student Name
Miami Regional University
Date of Encounter:
Preceptor/Clinical Site:
Clinical Instructor: Dr. Rafael Camejo
Soap Note #
Main Diagnosis
( Exp: Soap Note #3 DX: Hypertension)
PATIENT INFORMATION
Name
: Mr. DT
Age
: 68-year-old
Gender at Birth:
Male
Gender Identity
: Male
Source
: Patient
Allergies
: PCN, Iodine
Current Medications:
· Atorvastatin tab 20 mg, 1-tab PO at bedtime
· ASA 81mg po daily
· Multi-Vitamin Centrum Silver
PMH:
Hypercholesterolemia
Immunizations:
Influenza last 2018-year, tetanus, and hepatitis A and B 4 years ago.
Preventive Care
: Coloscopy 5 years ago (Negative)
Surgical History
: Appendectomy 47 years ago.
Family History
: Father- died 81 does not report information
Mother-alive, 88 years old, Diabetes Mellitus, HTN
Daughter-alive, 34 years old, healthy
Social History
: No smoking history or illicit drug use, occasional alcoholic beverage consumption on social celebrations. Retired, widow, he lives alone.
Sexual Orientation
: Straight
Nutrition History
: Diets off and on, Does not each seafood
Subjective Data:
Chief Complaint
: “headaches” that started two weeks ago
Symptom analysis/HPI:
The patient is 65 years old male who complaining of episodes of headaches and on 3 different occasions blood pressure was measured, which was high (159/100, 158/98 and 160/100 respectively). Patient noticed the problem started two weeks ago and sometimes it is accompanied by dizziness. He states that he has been under stress in his workplace for the last month. Patient denies chest pain, palpitation, shortness of breath, nausea or vomiting.
Review of Systems (ROS)
CONSTITUTIONAL
: Denies fever or chills. Denies weakness or weight loss.
NEUROLOGIC
: Headache and dizziness as describe above. Denies changes in LOC. Denies history of tremors or seizures.
HEENT
: HEAD: Denies any head injury, or change in LOC. Eyes: Denies any changes in vision, diplopia or blurred vision. Ear: Denies pain in the ears. Denies loss of hearing or drainage. Nose: Denies nasal drainage, congestion. THROAT: Denies throat or neck pain, hoarseness, difficulty swallowing.
RESPIRATORY
: Patient denies shortness of breath, cough or hemoptysis.
CARDIOVASCULAR
: No chest pain, tachycardia. No orthopnea or paroxysmal nocturnal
dyspnea.
GASTROINTESTINAL
: Denies abdominal pain or discomfort. Denies flatulence, nausea, vomiting or
diarrhea.
GENITOURINARY
: Denies hematuria, dysuria or change in urinary frequency. Denies difficulty starting/stopping stream of urine or incontinence.
MUSCULOSKELETAL
: Denies falls or pain. Denies hearing a clicking or snapping sound.
SKIN
: No change of coloration such as cyanosis or jaundice, no rashes or pruritus.
Objective Data:
VITAL SIGNS:
Temperature: 98.5 °F, Pulse: 87, BP: 159/92 mmhg, RR 20, PO2-98% on room air, Ht- 6’4”, Wt 200 lb, BMI 25. Report pain 2/10.
GENERAL APPREARANCE
.
SOAP NotePatient Initials RA Pt. Encounter Number .docxpbilly1
SOAP Note
Patient Initials: RA Pt. Encounter Number: 1
Date: 10/1/20 Age: 23 Sex: female
Allergies: NKA Advanced Directives: none
SUBJECTIVE
CC: “I have been having heavy periods for 4-5 months now. I feel tired and dizzy most days”
HPI: 23-year-old came to the clinic today complaining of heavy menstrual periods happening for the past 4 to 5 months. Accompanying the heavy flow, patient states that she has moderate cramps. Pt describes the pain as stabbing and its 3 out of the 0-10 scale. Patient does not take any medications for the pain. The pain is decreased by applying warm compresses to the lower abdominal area. In addition, patient complains of feeling dizziness and tiredness most of the times.
Current Medications: none
PMH Medication Intolerances: NONE Chronic Illnesses/Major traumas: NONE Screening Hx/Immunizations Hx: Vaccinations up to date, most recent pap smear 12/19 – negative Hospitalizations/Surgeries: None
Family History:Father: Alive, No medical history Mother: Alive, Htn
Social History: Patient is a full-time college student and part time employee at Publix as cashier. Pt lives at home with parents and denies having had a sexual partner for the past year. Patient denies the use of cigars, alcohol, or illegal drugs.
ROS
GeneralDenies recent weight loss, fever, change in appetite or headaches. She denies chills or night sweats. CardiovascularDenies palpitations, chest pain, orthopnea, and claudication. Reports episodes of hypotension.
SkinDenies bruising, skin rash, or discoloration. Denies changes in moles or skin breakdown. RespiratoryDenies shortness of breath, abnormal sputum, cough, or wheezing.
EyesDenies pain, redness, loss of vision, double or blurred vision GastrointestinalDenies abdominal pain, decreased appetite, nausea, or vomiting. Denies food intolerances and changes in stool
EarsDenies ear pain, ear infections, or tinnitus Genitourinary/GynecologicalDenies dysuria, flank pain, and hematuria. Denies abnormal vaginal discharge or itching. Denies STI history. Reports heavy menstrual periods lasting 5 to 6 days, associated with cramping; every 28 days. OBSTETRIC/GYNECOLOGICAL Hx:Menarche: 11 years LMP: 09/15/20 G 0 T 0 P 0 A 0 L 0 Birth Control/Type: NoneMenopause: no Sexually Active: yes STD Hx: None
Nose/Mouth/ThroatDenies nasal pain, congestion, epistaxis, or postnasal drip. Denies pain in mouth, bleeding gums, or dry mouth. Denies pain in throat, hoarseness, difficulty or painful swallowing. MusculoskeletalDenies muscle pain or joint pain. Denies limited range of motion
BreastDenies breast tenderness, discharge, redness, or lumps. NeurologicalDenies headache, dizziness, seizures, or memory loss.
Heme/Lymph/EndoPt denies bruising PsychiatricDenies mood changes, irritability, or changes in concentration. Denies hav.
SOAO NotePatient Initials S.MPt. Encounter Number 2 .docxpbilly1
SOAO Note
Patient Initials: S.M
Pt. Encounter Number: 2
Date: 10/12/2020
Age: 61
Sex: Female
Allergies: NKA
Advanced Directives: No
SUBJECTIVE
Chief Complaint: "I have a lump on my right breast."
HPI: S.M is a 61-year-old, Hispanic, female who presents to the office alarmed by a painful lump in her right breast that she discovered while showering. S.M reports the pain started 2 days ago while in the shower. The pain is felt when touching the right breast, and it felt on light touch. Current pain level is now 5/10. She does not report any skin changes. Patient denies any history of herbal medicine use and is currently on no medication. Pain gets worse with movement and with lifting weight. Pain is relieved with rest and medication. S.M gets some short relief with pain reliever ibuprofen 200mg that she takes twice a day for the past two days.
Past Medical History
Medication Intolerances: No known drug intolerance
Chronic Illnesses/Major traumas: The patient denies any history of major trauma.
Screening Hx/Immunizations Hx: last mammogram, which was normal, was 2 years ago.
OBGYN: Menarche at 10; LMP 2 weeks ago; last PAP 2019/Normal; GTPAL: 11001 score; no previous history of STDs. S.M is sexually active, have had 2 sexual partners in the past. S.M used condoms with previous partners. No previous gyn diagnoses or procedures done in the past.
Hospitalizations/Surgeries: Hospitalized once for delivery
Family History: There is no history of malignancy in first-degree relatives. She has one sister, age 58, who is in good health. Mother died at age 70; father died at age 64, from unknown causes.
Social History: S.M is married with one child. No use of alcohol; drinks wine socially; drinks one cup of coffee sometime to start her day at work. Never uses drugs.
Review of System
Constitutional: No significant gain/loss weight, no chills, no malaise or fatigue; no night sweats, no exercise intolerance. She does not report any skin changes. She has not experienced fever, weight loss, headache, nausea, vomiting, dizziness, or bone pain.
Skin: Denies rashes, pigmentation changes, lesions, or hair or nail changes.
Eyes: denies vision changes, diplopia, blurred vision, reports wearing eyeglasses.
Ears: Denies loss of hearing, ear pain, drainage, sensation of ears feeling full, ringing in the ear, or ear trauma.
Nose/Mouth/Throat: Denies sore throat, hoarseness, difficulty swallowing, postnasal
drip. No report of mouth or lips sore, bleeding gums, ulcerations or lesions of tongue or
mucosa; no dentures or dental appliances, or missing teeth reported.
Breast: Refers to right breast pain, or discomfort to right breast. Reports some brownish nipple discharges when squeezing the nipple and denies any breast trauma.
Heme/Lymph/Endo: Denies history of anemia, no bruising, no abnormal bleeding, and no swollen glands.
Cardiovascular: Denies chest pain, palpitations, orthopnea, edema, claudicati.
Soap Note # Main Diagnosis ( Exp: H&P Note #3 DX: Hypertension)
Student Name
Miami Regional University
Date of Encounter:
Preceptor/Clinical Site:
Clinical Instructor: Dr. Rafael Camejo
Soap Note #
Main Diagnosis
( Exp: Soap Note #3 DX: Hypertension)
PATIENT INFORMATION
Name
: Mr. DT
Age
: 68-year-old
Gender at Birth:
Male
Gender Identity
: Male
Source
: Patient
Allergies
: PCN, Iodine
Current Medications:
· Atorvastatin tab 20 mg, 1-tab PO at bedtime
· ASA 81mg po daily
· Multi-Vitamin Centrum Silver
PMH:
Hypercholesterolemia
Immunizations:
Influenza last 2018-year, tetanus, and hepatitis A and B 4 years ago.
Preventive Care
: Coloscopy 5 years ago (Negative)
Surgical History
: Appendectomy 47 years ago.
Family History
: Father- died 81 does not report information
Mother-alive, 88 years old, Diabetes Mellitus, HTN
Daughter-alive, 34 years old, healthy
Social History
: No smoking history or illicit drug use, occasional alcoholic beverage consumption on social celebrations. Retired, widow, he lives alone.
Sexual Orientation
: Straight
Nutrition History
: Diets off and on, Does not each seafood
Subjective Data:
Chief Complaint
: “headaches” that started two weeks ago
Symptom analysis/HPI:
The patient is 65 years old male who complaining of episodes of headaches and on 3 different occasions blood pressure was measured, which was high (159/100, 158/98 and 160/100 respectively). Patient noticed the problem started two weeks ago and sometimes it is accompanied by dizziness. He states that he has been under stress in his workplace for the last month. Patient denies chest pain, palpitation, shortness of breath, nausea or vomiting.
Review of Systems (ROS)
CONSTITUTIONAL
: Denies fever or chills. Denies weakness or weight loss.
NEUROLOGIC
: Headache and dizziness as describe above. Denies changes in LOC. Denies history of tremors or seizures.
HEENT
: HEAD: Denies any head injury, or change in LOC. Eyes: Denies any changes in vision, diplopia or blurred vision. Ear: Denies pain in the ears. Denies loss of hearing or drainage. Nose: Denies nasal drainage, congestion. THROAT: Denies throat or neck pain, hoarseness, difficulty swallowing.
RESPIRATORY
: Patient denies shortness of breath, cough or hemoptysis.
CARDIOVASCULAR
: No chest pain, tachycardia. No orthopnea or paroxysmal nocturnal
dyspnea.
GASTROINTESTINAL
: Denies abdominal pain or discomfort. Denies flatulence, nausea, vomiting or
diarrhea.
GENITOURINARY
: Denies hematuria, dysuria or change in urinary frequency. Denies difficulty starting/stopping stream of urine or incontinence.
MUSCULOSKELETAL
: Denies falls or pain. Denies hearing a clicking or snapping sound.
SKIN
: No change of coloration such as cyanosis or jaundice, no rashes or pruritus.
Objective Data:
VITAL SIGNS:
Temperature: 98.5 °F, Pulse: 87, BP: 159/92 mmhg, RR 20, PO2-98% on room air, Ht- 6’4”, Wt 200 lb, BMI 25. Report pain 2/10.
GENERAL APPREARANCE
: The patient is aler.
SOAP NOTE
Name:
N.C
Date:
10/26/2020
Time:
09.30 h
Age:
5-year-old
Sex:
M
CC:
"I have sore throat"
HPI:
A 5 y/o Hispanic male presents to the clinic complaining of sore throat that started 3 days ago. Describes that occasionally feels like “piercing or burning” pain that it is constant. Also, that is very painful to swallow. Mother states patient developed cold symptoms (cough, sneezing) about 5 days ago, sore throat started 3 days ago, and fever of 101.5 F began 24h ago. Patient added that the pain varies in intensity, rated anywhere from 8 to 9 on a Wong-Baker scale when eating or drinking, but at this moment rated his pain at 5. Reports that pain is not radiating to any surrounded area and “is better when drinking sips of a cold liquids like water or Kool-Aid or takes Ice cream”. Mother also states that fever somehow is relieved by rest and Tylenol. Confirms that his appetite has decreased in the last 3 days.
Medications:
Tylenol OTC PO PRN
PMH
Allergies: NKDA
Medication Intolerances: None
Chronic Illnesses/Major traumas: None
Hospitalizations/Surgeries: None
Immunizations:
- According to CDC for his age group, he is up to date with the following vaccines
• Influenza 2019
• Tdap 5th dose
• MMR 2nd dose
• Polio IVP 4th dose
• Chickenpox (Varicella) 2nd dose
Family History:
Mother: Alive – no significant medical history
Father: Alive - HTN
Sister: 8 years old healthy
Brother: 2 days old healthy
Social History
Lives with both parents and siblings. Appears comfortable and happy with mother in the room. Neither parents smoke. Patient began kindergarten this year at local public school.
General
Patient reports sore throat, but overall healthy, appropriate weight and height for age, usually very active but mostly lying around the past few days per mom.
Cardiovascular
Denies chest pain or palpitations.
Skin
Denies rash, inflammation, pain, tenderness, or skin lesion.
Respiratory
Denies any cough, wheezing, hemoptysis, dyspnea, pneumonia hx, TB exposure or symptoms per mom, or SOB.
Eyes
Denies use of corrective lenses or glasses, blurred vision, or visual changes of any kind.
ENT
Denies ear pain, hearing loss, ringing in ears, discharge. Reports no sinus problems, or nose bleeding. Complains of sore throat and aggravating pain when swallowing. Goes to dentist every 6 months per mom.
Gastrointestinal
Denies diarrhea, abdominal pain, or heartburn. He had his last bowel movement this morning and goes at least once a day.
Genitourinary
Denies urgency, frequency or burning and pain with urination. Reports no hematuria or change in color of urine. Denies penile pain.
Musculoskeletal
Denies back pain, joint swelling, stiffness, or muscle pain.
Heme/Lymph/Endo
Denies fatigue. Mother states swollen/tender cervical lymph nodes. Patient is appropriate size and weight for his age.
Neurological
Denies any syncope, seizures, transient paralysis, paresthesi.
Mrs. Jones is a 32 year old Caucasian female who presents for fo.docxgriffinruthie22
Mrs. Jones is a 32 year old Caucasian female who presents for follow up on her gestational diabetes. She is 3 months postpartum and was diagnosed with gestational diabetes. This was her first pregnancy. She has a strong family history of diabetes and was told to get it checked out once she stopped breastfeeding. She has not checked her glucose since she came home from the hospital, stating she has been too busy.
Allergies: Sulfa
Current medications: Multivitamin
PMH: Gestational Diabetes
PSH: Tonsillectomy, Wisdom teeth extraction
Social: Denies tobacco, Alcohol, or illegal drug use. She is married and lives with her husband and new baby. She works as an elementary teacher. She follows a regular diet and walks 2 days a week when she has recess duty.
Immunizations: flu: 2019
Family: Father: alive, +DM, CAD, Hyperlipidemia, Mother: alive, +DM, CKD
ROS:
Constitutional: Complains of increase fatigue
HEENT: Denies any headache, nasal congestion, ear pain
Cardiovascular: Denies chest pain
Respiratory: Denies any SOB or DOE
GI: Denies any issues, last BM 1 day ago.
GU: Denies any painful urination, urgency, hesitancy
Musculoskeletal: denies.
Neurological: Denies
Psychiatric: Denies suicidal ideations, depression. Does report difficulty falling asleep
Endocrine: Denies any weight changes, intolerance to heat/cold
Hematologic/ Lymphatic: Denies any bruising
OBJECTIVE:
Vital signs: Ht: 66, Wt: 185, BP 130/78, HR 76, Resp: 16, SaO2: 98%
Constitutional: Well developed, overweight female
HEENT: Oropharynx pink, moist, no lesions or exudate. Tonsils 1+ bilaterally. Teeth in good repair, no cavities noted. Tongue smooth, pink, no lesions, protrudes in midline. Neck supple. No cervical lymphadenopathy or tenderness noted. Thyroid midline, small and firm without palpable masses
Cardiovascular: RRR, No murmurs or rubs noted.
Respiratory: Clear all fields
GI: Abdomen round, soft, with bowel sounds noted in all four quadrants.
GU: Deferred
Musculoskeletal: Crepitus noted bilateral knees, fluid wave noted to Rt knee
Integumentary: Skin warm and dry, No rashes noted
Neuro: Follows commands without difficulty
Working with your group, utilize the above case study a, develop a Voice Over PowerPoint presentation for your patient covering the problems identified in the case study and content in Unit 3 of Edelman, Kudzama, & Mandle (2018). Include the following:
Nutrition Counseling for Health Promotion
Exercise
Stress Management
.
1) Naïve T cells have the potential to differentiate into several MartineMccracken314
1) Naïve T cells have the potential to differentiate into several types of effector cells. In the space below, describe the roles and activities of each of these cells:
TH1 cells
TH2 cells
TH17 cells
TFH cells
2) Use the following diagram to compare and contrast systemic immunity and mucosal immunity.
Systemic
Both Systemic and Mucosal
Mucosal
ordinary surface epithelia
Why is there a need for these differences in the first place?
CDC Sexually Transmitted Diseases Case Study.
Read the patient case study below
General:
The patient is a young seventeen-year-old female who came to the clinic with complaint of abdominal pain.
Chief Complaint:
Kim reports "I've been having pain in my stomach for several weeks." She describes the pain as being sharp and being constant. She stated the pain often occurs on both sides of her lower abdominal. She has been experiencing the pain for the past two weeks. The pain has gotten worse since then.
Reliability and Source of History:
The patient is alert and oriented and able to answer most of the questions.
Source & Reliability of History:
O – "I have been having pain in my stomach for several weeks now.” she stated that the pain has lasted for two weeks without any relief.
L – Both sides of her lower stomach
D – The patient reported that she has been having this bilateral lower stomach pain for the last two weeks, However, the symptoms got worse since the pain started ago.
C – She stated that since the onset of the pain, her pain has remained constant without any relieve and aggravating factor. The pain is firm regardless of the time or day or event. She further stated that her symptoms get worse. The patient states that she is unaware of what caused the pain or how the pain started; however, she stated that taking pills could relieve her stomach pain and stop her bleeding
A – She stated that the pain remains constant. She also stated that she is unaware of what caused the pain or how the pain started.
R – She stated that the pain remains steady and does not go away or radiate to other areas.
T- she reported feeling uncomfortable doing her regular shores due to the pain.
Past Medical history:
Patient is asthmatic; however, her asthma is under control. She knows known history of any other condition or never been hospitalized.
Family History:
She is the second in a family of four who are all alive and healthy. There is no history of any chronic condition in the family.
Social History:
Patient is a regularly active young woman; she is single and does moderately active exercise. However, she stated that her daily activity and chores has recently reduced due to her recent symptoms of pain. She also stated to have no appetite secondary to her recent pain. She also stated that her stress level may be related with her college. She has no history of alcohol, smoking, or had never smoked in her life. She has not used any ...
1) Naïve T cells have the potential to differentiate into several AbbyWhyte974
1) Naïve T cells have the potential to differentiate into several types of effector cells. In the space below, describe the roles and activities of each of these cells:
TH1 cells
TH2 cells
TH17 cells
TFH cells
2) Use the following diagram to compare and contrast systemic immunity and mucosal immunity.
Systemic
Both Systemic and Mucosal
Mucosal
ordinary surface epithelia
Why is there a need for these differences in the first place?
CDC Sexually Transmitted Diseases Case Study.
Read the patient case study below
General:
The patient is a young seventeen-year-old female who came to the clinic with complaint of abdominal pain.
Chief Complaint:
Kim reports "I've been having pain in my stomach for several weeks." She describes the pain as being sharp and being constant. She stated the pain often occurs on both sides of her lower abdominal. She has been experiencing the pain for the past two weeks. The pain has gotten worse since then.
Reliability and Source of History:
The patient is alert and oriented and able to answer most of the questions.
Source & Reliability of History:
O – "I have been having pain in my stomach for several weeks now.” she stated that the pain has lasted for two weeks without any relief.
L – Both sides of her lower stomach
D – The patient reported that she has been having this bilateral lower stomach pain for the last two weeks, However, the symptoms got worse since the pain started ago.
C – She stated that since the onset of the pain, her pain has remained constant without any relieve and aggravating factor. The pain is firm regardless of the time or day or event. She further stated that her symptoms get worse. The patient states that she is unaware of what caused the pain or how the pain started; however, she stated that taking pills could relieve her stomach pain and stop her bleeding
A – She stated that the pain remains constant. She also stated that she is unaware of what caused the pain or how the pain started.
R – She stated that the pain remains steady and does not go away or radiate to other areas.
T- she reported feeling uncomfortable doing her regular shores due to the pain.
Past Medical history:
Patient is asthmatic; however, her asthma is under control. She knows known history of any other condition or never been hospitalized.
Family History:
She is the second in a family of four who are all alive and healthy. There is no history of any chronic condition in the family.
Social History:
Patient is a regularly active young woman; she is single and does moderately active exercise. However, she stated that her daily activity and chores has recently reduced due to her recent symptoms of pain. She also stated to have no appetite secondary to her recent pain. She also stated that her stress level may be related with her college. She has no history of alcohol, smoking, or had never smoked in her life. She has not used any ...
Soap notes will be uploaded to Moodle and put through TURN-It-In (anWilheminaRossi174
Soap notes will be uploaded to Moodle and put through TURN-It-In (anti-Plagiarism program)
Turn it in Score must be less than 50% or will not be accepted for credit, must be your own work and in your own words. You can resubmit, Final submission will be accepted if less than 50%. Copy paste from websites or textbooks will not be accepted or tolerated. Please see College Handbook with reference to Academic Misconduct Statement.
Example:
PATIENT INFORMATION
Name: Mr. W.S.
Age: 65-year-old
Sex: Male
Source: Patient
Allergies: None
Current Medications: Atorvastatin tab 20 mg, 1-tab PO at bedtime
PMH: Hypercholesterolemia
Immunizations: Influenza last 2018-year, tetanus, and hepatitis A and B 4 years ago.
Surgical History: Appendectomy 47 years ago.
Family History: Father- died 81 does not report information
Mother-alive, 88 years old, Diabetes Mellitus, HTN
Daughter-alive, 34 years old, healthy
Social Hx: No smoking history or illicit drug use, occasional alcoholic beverage consumption on social celebrations. Retired, widow, he lives alone.
SUBJECTIVE:
Chief complain
: “headaches” that started two weeks ago
Symptom analysis/HPI:
The patient is 65 years old male who complaining of episodes of headaches and on 3 different occasions blood pressure was measured, which was high (159/100, 158/98 and 160/100 respectively). Patient noticed the problem started two weeks ago and sometimes it is accompanied by dizziness.He states that he has been under stress in his workplace for the last month.
Patient denies chest pain, palpitation, shortness of breath, nausea or vomiting.
ROS:
CONSTITUTIONAL
: Denies fever or chills. Denies weakness or weight loss.
NEUROLOGIC
: Headache and dizzeness as describe above. Denies changes in LOC. Denies history of tremors or seizures.
HEENT
: HEAD: Denies any head injury, or change in LOC. Eyes: Denies any changes in vision, diplopia or blurred vision. Ear: Denies pain in the ears. Denies loss of hearing or drainage. Nose: Denies nasal drainage, congestion. THROAT: Denies throat or neck pain, hoarseness, difficulty swallowing.
Respiratory
:Patient denies shortness of breath, cough or hemoptysis.
Cardiovascular
: No chest pain, tachycardia. No orthopnea or paroxysmal nocturnal
dyspnea.
Gastrointestinal
:Denies abdominal pain or discomfort.Denies flatulence, nausea, vomiting or
diarrhea.
Genitourinary
: Denies hematuria, dysuria or change in urinary frequency. Denies difficulty starting/stopping stream of urine or incontinence.
MUSCULOSKELETAL
: Denies falls or pain. Denies hearing a clicking or snapping sound.
Skin
: No change of coloration such as cyanosis or jaundice, no rashes or pruritus.
Objective Data
CONSTITUTIONAL
: Vital signs: Temperature: 98.5 °F, Pulse: 87, BP: 159/92 mmhg, RR 20, PO2-98% on room air, Ht- 6’4”, Wt 200 lb, BMI 25. Report pain 0/10.
General appearance: The patient is alert and oriented x 3. No acute distress noted.
NEUROLOGIC:
Alert, CNII-XII grossly intac ...
(Student Name) UniversityDate of EncounterPreceptorCliniMoseStaton39
(Student Name)
University
Date of Encounter:
Preceptor/Clinical Site:
Clinical Instructor:
Soap Note # Main Diagnosis ( Exp: Soap Note #3 DX: Hypertension)
PATIENT INFORMATION
Name: Mr. DT
Age: 68-year-old
Gender at Birth: Male
Gender Identity: Male
Source: Patient
Allergies: PCN, Iodine
Current Medications:
· Atorvastatin tab 20 mg, 1-tab PO at bedtime
· ASA 81mg po daily
· Multi-Vitamin Centrum Silver
PMH: Hypercholesterolemia
Immunizations: Influenza last 2018-year, tetanus, and hepatitis A and B 4 years ago.
Preventive Care: Coloscopy 5 years ago (Negative)
Surgical History: Appendectomy 47 years ago.
Family History: Father- died 81 does not report information
Mother-alive, 88 years old, Diabetes Mellitus, HTN
Daughter-alive, 34 years old, healthy
Social History: No smoking history or illicit drug use, occasional alcoholic beverage consumption on social celebrations. Retired, widow, he lives alone.
Sexual Orientation: Straight
Nutrition History: Diets off and on, Does not each seafood
Subjective Data:
Chief Complaint: “headaches” that started two weeks ago
Symptom analysis/HPI:
The patient is 65 years old male who complaining of episodes of headaches and on 3 different occasions blood pressure was measured, which was high (159/100, 158/98 and 160/100 respectively). Patient noticed the problem started two weeks ago and sometimes it is accompanied by dizziness. He states that he has been under stress in his workplace for the last month. Patient denies chest pain, palpitation, shortness of breath, nausea or vomiting.
Review of Systems (ROS)
CONSTITUTIONAL: Denies fever or chills. Denies weakness or weight loss. NEUROLOGIC: Headache and dizziness as describe above. Denies changes in LOC. Denies history of tremors or seizures.
HEENT: HEAD: Denies any head injury, or change in LOC. Eyes: Denies any changes in vision, diplopia or blurred vision. Ear: Denies pain in the ears. Denies loss of hearing or drainage. Nose: Denies nasal drainage, congestion. THROAT: Denies throat or neck pain, hoarseness, difficulty swallowing.
RESPIRATORY: Patient denies shortness of breath, cough or hemoptysis.
CARDIOVASCULAR: No chest pain, tachycardia. No orthopnea or paroxysmal nocturnal
dyspnea.
GASTROINTESTINAL: Denies abdominal pain or discomfort. Denies flatulence, nausea, vomiting or
diarrhea.
GENITOURINARY: Denies hematuria, dysuria or change in urinary frequency. Denies difficulty starting/stopping stream of urine or incontinence.
MUSCULOSKELETAL: Denies falls or pain. Denies hearing a clicking or snapping sound.
SKIN: No change of coloration such as cyanosis or jaundice, no rashes or pruritus.
Objective Data:
VITAL SIGNS: Temperature: 98.5 °F, Pulse: 87, BP: 159/92 mmhg, RR 20, PO2-98% on room air, Ht- 6’4”, Wt 200 lb, BMI 25. Report pain 2/10.
GENERAL APPREARANCE: The patient is alert and oriented x 3. No acute distress noted. NEUROLOGIC: Alert, CNII-XII grossly intact, oriented to person, ...
(Student Name) UniversityDate of EncounterPreceptorCliniSilvaGraf83
(Student Name)
University
Date of Encounter:
Preceptor/Clinical Site:
Clinical Instructor:
Soap Note # Main Diagnosis ( Exp: Soap Note #3 DX: Hypertension)
PATIENT INFORMATION
Name: Mr. DT
Age: 68-year-old
Gender at Birth: Male
Gender Identity: Male
Source: Patient
Allergies: PCN, Iodine
Current Medications:
· Atorvastatin tab 20 mg, 1-tab PO at bedtime
· ASA 81mg po daily
· Multi-Vitamin Centrum Silver
PMH: Hypercholesterolemia
Immunizations: Influenza last 2018-year, tetanus, and hepatitis A and B 4 years ago.
Preventive Care: Coloscopy 5 years ago (Negative)
Surgical History: Appendectomy 47 years ago.
Family History: Father- died 81 does not report information
Mother-alive, 88 years old, Diabetes Mellitus, HTN
Daughter-alive, 34 years old, healthy
Social History: No smoking history or illicit drug use, occasional alcoholic beverage consumption on social celebrations. Retired, widow, he lives alone.
Sexual Orientation: Straight
Nutrition History: Diets off and on, Does not each seafood
Subjective Data:
Chief Complaint: “headaches” that started two weeks ago
Symptom analysis/HPI:
The patient is 65 years old male who complaining of episodes of headaches and on 3 different occasions blood pressure was measured, which was high (159/100, 158/98 and 160/100 respectively). Patient noticed the problem started two weeks ago and sometimes it is accompanied by dizziness. He states that he has been under stress in his workplace for the last month. Patient denies chest pain, palpitation, shortness of breath, nausea or vomiting.
Review of Systems (ROS)
CONSTITUTIONAL: Denies fever or chills. Denies weakness or weight loss. NEUROLOGIC: Headache and dizziness as describe above. Denies changes in LOC. Denies history of tremors or seizures.
HEENT: HEAD: Denies any head injury, or change in LOC. Eyes: Denies any changes in vision, diplopia or blurred vision. Ear: Denies pain in the ears. Denies loss of hearing or drainage. Nose: Denies nasal drainage, congestion. THROAT: Denies throat or neck pain, hoarseness, difficulty swallowing.
RESPIRATORY: Patient denies shortness of breath, cough or hemoptysis.
CARDIOVASCULAR: No chest pain, tachycardia. No orthopnea or paroxysmal nocturnal
dyspnea.
GASTROINTESTINAL: Denies abdominal pain or discomfort. Denies flatulence, nausea, vomiting or
diarrhea.
GENITOURINARY: Denies hematuria, dysuria or change in urinary frequency. Denies difficulty starting/stopping stream of urine or incontinence.
MUSCULOSKELETAL: Denies falls or pain. Denies hearing a clicking or snapping sound.
SKIN: No change of coloration such as cyanosis or jaundice, no rashes or pruritus.
Objective Data:
VITAL SIGNS: Temperature: 98.5 °F, Pulse: 87, BP: 159/92 mmhg, RR 20, PO2-98% on room air, Ht- 6’4”, Wt 200 lb, BMI 25. Report pain 2/10.
GENERAL APPREARANCE: The patient is alert and oriented x 3. No acute distress noted. NEUROLOGIC: Alert, CNII-XII grossly intact, oriented to person, ...
ABDOMINAL PAIN CASE HISTORY FOR DIAGNOSTIC SYNDROME SLIDESHAREBRINCELET M BIJU
INTRODUCTION
Abdominal pain refers to discomfort that is felt between the chest and the groin.,which can be acute or chronic on presentation.
Categorised into 4 quadrant and 9 regions for analysis of underlying pathologies and their localization ,patient may also present with ;-Bloating, N/V, diarrhea or constipation, fever, visible swelling or tenderness.
It Can occur due to Gastrointestinal pathologies like peptic ulcer ,appendicitis, obstructions, cholecystitis etc or gynecologycal, vascular, peritoneal pathologies
EPIDEMIOLOGY
5 – 10% of all ED visits.
Among them, 14 – 40 % patients need surgical intervention
Most common diagnosis is Non specific
Males were more affected than females with male to female ratio of 1.14 : 1
Highest number of patients were in 15 – 24 years of life
Most common cause found to be acute appendicitis for acute abdomen in a range of 57.5 % of total admission.
CAUSES
Gastrointestinal
Gastrointestinal
Gastroduodenal
Peptic ulcer
Gastritis
Malignancy
Gastric volvulus
Intestinal
Appendicitis
Obstruction
Inverticulitis
Gastroenteritis
Mesentric adenitis
Strangulated hernia
Inflammatory bowel disease
Intussusception
Volvulus
TB
Case
History of Present Illness
A 26-year-old woman comes to the office because of a 3-day history of lower abdominal pain. She is 18 weeks pregnant by dates. The patient describes the pain as sharp, steady, and radiating across her lower abdomen bilaterally. Last night she developed new nausea and vomiting. She has not been able to keep down any food or drink this morning. She had a normal bowel movement yesterday. She says she felt cold and shivering this morning, followed by feeling warm; however, she did not check her temperature. She denies vaginal bleeding.
General: Patient feels generally weak and ill but was in her usual state of health until 3 days ago. She has gained approximately 5 lbs (2.3 kg) in the pregnancy so far.
Skin: She denies rash.
HEENT: Her mouth feels dry. No headache, nasal congestion, or sore throat.
Pulmonary: She denies cough or shortness of breath.
Cardiovascular: She denies chest pain or palpitations.
Gastrointestinal: She has had a decreased appetite for 1 day and has been unable to keep any food or drink down this morning due to nausea and vomiting. She has not had diarrhea or constipation.
Genitourinary: She reports a frequent urge to urinate and a sensation of incomplete bladder emptying for the past 3 days. No dysuria or hematuria. She is G1P0A0 and has been seeing an obstetrician for all routine visits and testing. No vaginal bleeding.
Musculoskeletal: She reports mild diffuse low back pain. No generalized muscle aches.
Neurologic: Noncontributory
Past Medical History
Medical history: Mild intermittent asthma diagnosed in childhood requiring only occasional rescue inhaler use, no hospitalizations for asthma. She is otherwise healthy.
Surgical history: Wisdom teeth removed at age 18.
Medications: Albuterol inhaler as needed, about once a month.
Soap notes will be uploaded to Moodle and put through TURN-It-In (anti.docxhenry34567896
Soap notes will be uploaded to Moodle and put through TURN-It-In (anti-Plagiarism program)
Turn it in Score must be less than 50% or will not be accepted for credit, must be your own work and in your own words. You can resubmit, Final submission will be accepted if less than 50%. Copy paste from
websites
or textbooks will not be accepted or tolerated. Please see College Handbook with reference to Academic Misconduct Statement.
Example:
PATIENT INFORMATION
Name: Mr. W.S.
Age: 65-year-old
Sex: Male
Source: Patient
Allergies: None
Current Medications: Atorvastatin tab 20 mg, 1-tab PO at bedtime
PMH: Hypercholesterolemia
Immunizations: Influenza last 2018-year, tetanus, and hepatitis A and B 4 years ago.
Surgical History: Appendectomy 47 years ago.
Family History: Father- died 81 does not report information
Mother-alive, 88 years old, Diabetes Mellitus, HTN
Daughter-alive, 34 years old, healthy
Social Hx: No smoking history or illicit drug use, occasional alcoholic beverage consumption on social celebrations. Retired, widow, he lives alone.
SUBJECTIVE:
Chief complain
: “headaches†that started two weeks ago
Symptom analysis/HPI:
The patient is 65 years old male who complaining of episodes of headaches and on 3 different occasions blood pressure was measured, which was high (159/100, 158/98 and 160/100 respectively). Patient noticed the problem started two weeks ago and sometimes it is accompanied by dizziness. He states that he has been under stress in his workplace for the last month.
Patient denies chest pain, palpitation, shortness of breath, nausea or vomiting.
ROS:
CONSTITUTIONAL
: Denies fever or chills. Denies weakness or weight loss.
NEUROLOGIC
: Headache and dizziness as describe above. Denies changes in LOC. Denies history of tremors or seizures.
HEENT
: HEAD: Denies any head injury, or change in LOC. Eyes: Denies any changes in vision, diplopia or blurred vision. Ear: Denies pain in the ears. Denies loss of hearing or drainage. Nose: Denies nasal drainage, congestion. THROAT: Denies throat or neck pain, hoarseness, difficulty swallowing.
Respiratory
: Patient denies shortness of breath, cough or hemoptysis.
Cardiovascular
: No chest pain, tachycardia. No orthopnea or paroxysmal nocturnal
dyspnea.
Gastrointestinal
: Denies abdominal pain or discomfort. Denies flatulence, nausea, vomiting or
diarrhea.
Genitourinary
: Denies hematuria, dysuria or change in urinary frequency. Denies difficulty starting/stopping stream of urine or incontinence.
MUSCULOSKELETAL
: Denies falls or pain. Denies hearing a clicking or snapping sound.
Skin
: No change of coloration such as cyanosis or jaundice, no rashes or pruritus.
Objective Data
CONSTITUTIONAL
: Vital signs: Temperature: 98.5 °F, Pulse: 87, BP: 159/92 mmhg, RR 20, PO2-98% on room air, Ht- 6’4â€, Wt 200 lb, BMI 25. Report pain 0/10.
General appearance: The patient is alert and oriented x 3. No acute dist.
Social Media and the Modern Impact of InformaticsWrite an es.docxpbilly1
Social Media and the Modern Impact of Informatics
Write an essay addressing each of the following points/questions. Be sure to completely answer all the questions for each number item. There should be three sections, one for each item number below, as well the introduction (heading is the title of the essay) and conclusion paragraphs. Separate each section in your paper with a clear heading that allows your professor to know which bullet you are addressing in that section of your paper. Support your ideas with at least three (3) scholarly citations using APA citations in your essay. Make sure to reference the citations using the APA writing style for the essay. The cover page and reference page do not count towards the minimum word amount. Review the rubric criteria for this assignment.
Most people remember the story below that made national headlines. As most Americans have smart phones, tablets, and computers the utilization of social media is common place.
Finley, T. (2017, Sept. 20). Navy hospital removes staffers for calling babies ‘mini Satan’s’ on social media.
Parenting
.
If you were writing a hospital policy on smart phone and social media usage, what should be included in the policy?
What potential ethical and legal liabilities are there for the hospital and employees in the case presented above?
In 2007, Harvard University rescinded admission to 10 students after reviewing their social media post.
Do you feel potential employers, current employers, and colleges have the right to access your social media post? Do you feel employers and universities should make decisions based on your post?
Discuss the relationship between accreditation decisions, reimbursement, quality of care, informatics.
.
Social Media and the global marketplace Web 2.0 Business .docxpbilly1
Social Media and the global marketplace: Web 2.0
Business Models
Readings:
Wirtz, B.W., Schilke, O. and Ullrich, S., 2010. Strategic development of
business models: implications of the Web 2.0 for creating value on the
internet. Long Range Planning, 43(2), pp.272-290.
INB 20009 Managing the Global Marketplace
Lesson plan
• Social Media and digital business models
• Socio-cultural research (Verstehen school of thought)
1) Socio-Cultural Research: The social as capital
2) Socio-Cultural Research: The social as theatre
• Stages of Internationalisation
• A Strategic Approach to Internationalisation: A Traditional Versus a
‘Born-Global’ Approach :
• Implications and recommendations
PART 1
CONCEPTS
A BUSINESS MODEL
• The business model is a holistic management
approach that reflects the fundamental value
creation logic, value creation architecture and the
functioning of a company (Timmers 1998).
• A representation of a firm’s underlying core logic and
strategic choices for creating and capturing value
within a value network (Shafer, S.M., Smith, H.J.
and Linder, J.C., 2005 p.202).
A BUSINESS MODEL…contd
• Porter (1985) distinguishes nine value chain elements. Namely, as
primary elements inbound logistics, operations, outbound logistics,
marketing & sales, service; and as support activities technology
development, procurement, human resource management,
corporate infrastructure.
Components of a business model
Source: (Shafer, S.M., Smith, H.J. and Linder, J.C., 2005 p.202).
The 4C-Net-Business-Model typology
(Wirtz 2000; Wirtz and Lihotzky 2003, p. 522)
• A typology to structure the different business
models on the Internet within the B2C sector.
• Four basic business models are characterised
by different service offerings across Content,
Commerce, Context and Connection.
• The classification is considered as 4C-Net-
Business-Model typology (Wirtz 2000, p. 218).
Content, Commerce, Context and
Connection
• Content-orientated business models are used by firms -
such as The Wall Street Journal Online - that focus on
the collection, selection, compilation, distribution, and/or
presentation of online content.
• Their value proposition is to provide convenient, user-
friendly online access to various types of relevant
content.
Content, Commerce, Context and
Connection
• Commerce-orientated business models focus primarily
on the initiation, negotiation, payment and delivery
aspects of trade transactions using online media.
• Commerce-oriented firms, such as Amazon and Dell,
offer cost-efficient transactions for buyers and sellers of
goods and services.
• Companies focusing on this type of business model use
electronic Internet-based processes to substitute or
support traditional transaction functions and arenas,
creating direct revenue streams in the form of sales
revenues, as well as indirect revenue streams such as
commissions.
Content, Commer.
More Related Content
Similar to SOAP NOTE SAMPLE FORMAT FOR MRCName LPDateTime 1315.docx
SOAP NotePatient Initials RA Pt. Encounter Number .docxpbilly1
SOAP Note
Patient Initials: RA Pt. Encounter Number: 1
Date: 10/1/20 Age: 23 Sex: female
Allergies: NKA Advanced Directives: none
SUBJECTIVE
CC: “I have been having heavy periods for 4-5 months now. I feel tired and dizzy most days”
HPI: 23-year-old came to the clinic today complaining of heavy menstrual periods happening for the past 4 to 5 months. Accompanying the heavy flow, patient states that she has moderate cramps. Pt describes the pain as stabbing and its 3 out of the 0-10 scale. Patient does not take any medications for the pain. The pain is decreased by applying warm compresses to the lower abdominal area. In addition, patient complains of feeling dizziness and tiredness most of the times.
Current Medications: none
PMH Medication Intolerances: NONE Chronic Illnesses/Major traumas: NONE Screening Hx/Immunizations Hx: Vaccinations up to date, most recent pap smear 12/19 – negative Hospitalizations/Surgeries: None
Family History:Father: Alive, No medical history Mother: Alive, Htn
Social History: Patient is a full-time college student and part time employee at Publix as cashier. Pt lives at home with parents and denies having had a sexual partner for the past year. Patient denies the use of cigars, alcohol, or illegal drugs.
ROS
GeneralDenies recent weight loss, fever, change in appetite or headaches. She denies chills or night sweats. CardiovascularDenies palpitations, chest pain, orthopnea, and claudication. Reports episodes of hypotension.
SkinDenies bruising, skin rash, or discoloration. Denies changes in moles or skin breakdown. RespiratoryDenies shortness of breath, abnormal sputum, cough, or wheezing.
EyesDenies pain, redness, loss of vision, double or blurred vision GastrointestinalDenies abdominal pain, decreased appetite, nausea, or vomiting. Denies food intolerances and changes in stool
EarsDenies ear pain, ear infections, or tinnitus Genitourinary/GynecologicalDenies dysuria, flank pain, and hematuria. Denies abnormal vaginal discharge or itching. Denies STI history. Reports heavy menstrual periods lasting 5 to 6 days, associated with cramping; every 28 days. OBSTETRIC/GYNECOLOGICAL Hx:Menarche: 11 years LMP: 09/15/20 G 0 T 0 P 0 A 0 L 0 Birth Control/Type: NoneMenopause: no Sexually Active: yes STD Hx: None
Nose/Mouth/ThroatDenies nasal pain, congestion, epistaxis, or postnasal drip. Denies pain in mouth, bleeding gums, or dry mouth. Denies pain in throat, hoarseness, difficulty or painful swallowing. MusculoskeletalDenies muscle pain or joint pain. Denies limited range of motion
BreastDenies breast tenderness, discharge, redness, or lumps. NeurologicalDenies headache, dizziness, seizures, or memory loss.
Heme/Lymph/EndoPt denies bruising PsychiatricDenies mood changes, irritability, or changes in concentration. Denies hav.
SOAO NotePatient Initials S.MPt. Encounter Number 2 .docxpbilly1
SOAO Note
Patient Initials: S.M
Pt. Encounter Number: 2
Date: 10/12/2020
Age: 61
Sex: Female
Allergies: NKA
Advanced Directives: No
SUBJECTIVE
Chief Complaint: "I have a lump on my right breast."
HPI: S.M is a 61-year-old, Hispanic, female who presents to the office alarmed by a painful lump in her right breast that she discovered while showering. S.M reports the pain started 2 days ago while in the shower. The pain is felt when touching the right breast, and it felt on light touch. Current pain level is now 5/10. She does not report any skin changes. Patient denies any history of herbal medicine use and is currently on no medication. Pain gets worse with movement and with lifting weight. Pain is relieved with rest and medication. S.M gets some short relief with pain reliever ibuprofen 200mg that she takes twice a day for the past two days.
Past Medical History
Medication Intolerances: No known drug intolerance
Chronic Illnesses/Major traumas: The patient denies any history of major trauma.
Screening Hx/Immunizations Hx: last mammogram, which was normal, was 2 years ago.
OBGYN: Menarche at 10; LMP 2 weeks ago; last PAP 2019/Normal; GTPAL: 11001 score; no previous history of STDs. S.M is sexually active, have had 2 sexual partners in the past. S.M used condoms with previous partners. No previous gyn diagnoses or procedures done in the past.
Hospitalizations/Surgeries: Hospitalized once for delivery
Family History: There is no history of malignancy in first-degree relatives. She has one sister, age 58, who is in good health. Mother died at age 70; father died at age 64, from unknown causes.
Social History: S.M is married with one child. No use of alcohol; drinks wine socially; drinks one cup of coffee sometime to start her day at work. Never uses drugs.
Review of System
Constitutional: No significant gain/loss weight, no chills, no malaise or fatigue; no night sweats, no exercise intolerance. She does not report any skin changes. She has not experienced fever, weight loss, headache, nausea, vomiting, dizziness, or bone pain.
Skin: Denies rashes, pigmentation changes, lesions, or hair or nail changes.
Eyes: denies vision changes, diplopia, blurred vision, reports wearing eyeglasses.
Ears: Denies loss of hearing, ear pain, drainage, sensation of ears feeling full, ringing in the ear, or ear trauma.
Nose/Mouth/Throat: Denies sore throat, hoarseness, difficulty swallowing, postnasal
drip. No report of mouth or lips sore, bleeding gums, ulcerations or lesions of tongue or
mucosa; no dentures or dental appliances, or missing teeth reported.
Breast: Refers to right breast pain, or discomfort to right breast. Reports some brownish nipple discharges when squeezing the nipple and denies any breast trauma.
Heme/Lymph/Endo: Denies history of anemia, no bruising, no abnormal bleeding, and no swollen glands.
Cardiovascular: Denies chest pain, palpitations, orthopnea, edema, claudicati.
Soap Note # Main Diagnosis ( Exp: H&P Note #3 DX: Hypertension)
Student Name
Miami Regional University
Date of Encounter:
Preceptor/Clinical Site:
Clinical Instructor: Dr. Rafael Camejo
Soap Note #
Main Diagnosis
( Exp: Soap Note #3 DX: Hypertension)
PATIENT INFORMATION
Name
: Mr. DT
Age
: 68-year-old
Gender at Birth:
Male
Gender Identity
: Male
Source
: Patient
Allergies
: PCN, Iodine
Current Medications:
· Atorvastatin tab 20 mg, 1-tab PO at bedtime
· ASA 81mg po daily
· Multi-Vitamin Centrum Silver
PMH:
Hypercholesterolemia
Immunizations:
Influenza last 2018-year, tetanus, and hepatitis A and B 4 years ago.
Preventive Care
: Coloscopy 5 years ago (Negative)
Surgical History
: Appendectomy 47 years ago.
Family History
: Father- died 81 does not report information
Mother-alive, 88 years old, Diabetes Mellitus, HTN
Daughter-alive, 34 years old, healthy
Social History
: No smoking history or illicit drug use, occasional alcoholic beverage consumption on social celebrations. Retired, widow, he lives alone.
Sexual Orientation
: Straight
Nutrition History
: Diets off and on, Does not each seafood
Subjective Data:
Chief Complaint
: “headaches” that started two weeks ago
Symptom analysis/HPI:
The patient is 65 years old male who complaining of episodes of headaches and on 3 different occasions blood pressure was measured, which was high (159/100, 158/98 and 160/100 respectively). Patient noticed the problem started two weeks ago and sometimes it is accompanied by dizziness. He states that he has been under stress in his workplace for the last month. Patient denies chest pain, palpitation, shortness of breath, nausea or vomiting.
Review of Systems (ROS)
CONSTITUTIONAL
: Denies fever or chills. Denies weakness or weight loss.
NEUROLOGIC
: Headache and dizziness as describe above. Denies changes in LOC. Denies history of tremors or seizures.
HEENT
: HEAD: Denies any head injury, or change in LOC. Eyes: Denies any changes in vision, diplopia or blurred vision. Ear: Denies pain in the ears. Denies loss of hearing or drainage. Nose: Denies nasal drainage, congestion. THROAT: Denies throat or neck pain, hoarseness, difficulty swallowing.
RESPIRATORY
: Patient denies shortness of breath, cough or hemoptysis.
CARDIOVASCULAR
: No chest pain, tachycardia. No orthopnea or paroxysmal nocturnal
dyspnea.
GASTROINTESTINAL
: Denies abdominal pain or discomfort. Denies flatulence, nausea, vomiting or
diarrhea.
GENITOURINARY
: Denies hematuria, dysuria or change in urinary frequency. Denies difficulty starting/stopping stream of urine or incontinence.
MUSCULOSKELETAL
: Denies falls or pain. Denies hearing a clicking or snapping sound.
SKIN
: No change of coloration such as cyanosis or jaundice, no rashes or pruritus.
Objective Data:
VITAL SIGNS:
Temperature: 98.5 °F, Pulse: 87, BP: 159/92 mmhg, RR 20, PO2-98% on room air, Ht- 6’4”, Wt 200 lb, BMI 25. Report pain 2/10.
GENERAL APPREARANCE
: The patient is aler.
SOAP NOTE
Name:
N.C
Date:
10/26/2020
Time:
09.30 h
Age:
5-year-old
Sex:
M
CC:
"I have sore throat"
HPI:
A 5 y/o Hispanic male presents to the clinic complaining of sore throat that started 3 days ago. Describes that occasionally feels like “piercing or burning” pain that it is constant. Also, that is very painful to swallow. Mother states patient developed cold symptoms (cough, sneezing) about 5 days ago, sore throat started 3 days ago, and fever of 101.5 F began 24h ago. Patient added that the pain varies in intensity, rated anywhere from 8 to 9 on a Wong-Baker scale when eating or drinking, but at this moment rated his pain at 5. Reports that pain is not radiating to any surrounded area and “is better when drinking sips of a cold liquids like water or Kool-Aid or takes Ice cream”. Mother also states that fever somehow is relieved by rest and Tylenol. Confirms that his appetite has decreased in the last 3 days.
Medications:
Tylenol OTC PO PRN
PMH
Allergies: NKDA
Medication Intolerances: None
Chronic Illnesses/Major traumas: None
Hospitalizations/Surgeries: None
Immunizations:
- According to CDC for his age group, he is up to date with the following vaccines
• Influenza 2019
• Tdap 5th dose
• MMR 2nd dose
• Polio IVP 4th dose
• Chickenpox (Varicella) 2nd dose
Family History:
Mother: Alive – no significant medical history
Father: Alive - HTN
Sister: 8 years old healthy
Brother: 2 days old healthy
Social History
Lives with both parents and siblings. Appears comfortable and happy with mother in the room. Neither parents smoke. Patient began kindergarten this year at local public school.
General
Patient reports sore throat, but overall healthy, appropriate weight and height for age, usually very active but mostly lying around the past few days per mom.
Cardiovascular
Denies chest pain or palpitations.
Skin
Denies rash, inflammation, pain, tenderness, or skin lesion.
Respiratory
Denies any cough, wheezing, hemoptysis, dyspnea, pneumonia hx, TB exposure or symptoms per mom, or SOB.
Eyes
Denies use of corrective lenses or glasses, blurred vision, or visual changes of any kind.
ENT
Denies ear pain, hearing loss, ringing in ears, discharge. Reports no sinus problems, or nose bleeding. Complains of sore throat and aggravating pain when swallowing. Goes to dentist every 6 months per mom.
Gastrointestinal
Denies diarrhea, abdominal pain, or heartburn. He had his last bowel movement this morning and goes at least once a day.
Genitourinary
Denies urgency, frequency or burning and pain with urination. Reports no hematuria or change in color of urine. Denies penile pain.
Musculoskeletal
Denies back pain, joint swelling, stiffness, or muscle pain.
Heme/Lymph/Endo
Denies fatigue. Mother states swollen/tender cervical lymph nodes. Patient is appropriate size and weight for his age.
Neurological
Denies any syncope, seizures, transient paralysis, paresthesi.
Mrs. Jones is a 32 year old Caucasian female who presents for fo.docxgriffinruthie22
Mrs. Jones is a 32 year old Caucasian female who presents for follow up on her gestational diabetes. She is 3 months postpartum and was diagnosed with gestational diabetes. This was her first pregnancy. She has a strong family history of diabetes and was told to get it checked out once she stopped breastfeeding. She has not checked her glucose since she came home from the hospital, stating she has been too busy.
Allergies: Sulfa
Current medications: Multivitamin
PMH: Gestational Diabetes
PSH: Tonsillectomy, Wisdom teeth extraction
Social: Denies tobacco, Alcohol, or illegal drug use. She is married and lives with her husband and new baby. She works as an elementary teacher. She follows a regular diet and walks 2 days a week when she has recess duty.
Immunizations: flu: 2019
Family: Father: alive, +DM, CAD, Hyperlipidemia, Mother: alive, +DM, CKD
ROS:
Constitutional: Complains of increase fatigue
HEENT: Denies any headache, nasal congestion, ear pain
Cardiovascular: Denies chest pain
Respiratory: Denies any SOB or DOE
GI: Denies any issues, last BM 1 day ago.
GU: Denies any painful urination, urgency, hesitancy
Musculoskeletal: denies.
Neurological: Denies
Psychiatric: Denies suicidal ideations, depression. Does report difficulty falling asleep
Endocrine: Denies any weight changes, intolerance to heat/cold
Hematologic/ Lymphatic: Denies any bruising
OBJECTIVE:
Vital signs: Ht: 66, Wt: 185, BP 130/78, HR 76, Resp: 16, SaO2: 98%
Constitutional: Well developed, overweight female
HEENT: Oropharynx pink, moist, no lesions or exudate. Tonsils 1+ bilaterally. Teeth in good repair, no cavities noted. Tongue smooth, pink, no lesions, protrudes in midline. Neck supple. No cervical lymphadenopathy or tenderness noted. Thyroid midline, small and firm without palpable masses
Cardiovascular: RRR, No murmurs or rubs noted.
Respiratory: Clear all fields
GI: Abdomen round, soft, with bowel sounds noted in all four quadrants.
GU: Deferred
Musculoskeletal: Crepitus noted bilateral knees, fluid wave noted to Rt knee
Integumentary: Skin warm and dry, No rashes noted
Neuro: Follows commands without difficulty
Working with your group, utilize the above case study a, develop a Voice Over PowerPoint presentation for your patient covering the problems identified in the case study and content in Unit 3 of Edelman, Kudzama, & Mandle (2018). Include the following:
Nutrition Counseling for Health Promotion
Exercise
Stress Management
.
1) Naïve T cells have the potential to differentiate into several MartineMccracken314
1) Naïve T cells have the potential to differentiate into several types of effector cells. In the space below, describe the roles and activities of each of these cells:
TH1 cells
TH2 cells
TH17 cells
TFH cells
2) Use the following diagram to compare and contrast systemic immunity and mucosal immunity.
Systemic
Both Systemic and Mucosal
Mucosal
ordinary surface epithelia
Why is there a need for these differences in the first place?
CDC Sexually Transmitted Diseases Case Study.
Read the patient case study below
General:
The patient is a young seventeen-year-old female who came to the clinic with complaint of abdominal pain.
Chief Complaint:
Kim reports "I've been having pain in my stomach for several weeks." She describes the pain as being sharp and being constant. She stated the pain often occurs on both sides of her lower abdominal. She has been experiencing the pain for the past two weeks. The pain has gotten worse since then.
Reliability and Source of History:
The patient is alert and oriented and able to answer most of the questions.
Source & Reliability of History:
O – "I have been having pain in my stomach for several weeks now.” she stated that the pain has lasted for two weeks without any relief.
L – Both sides of her lower stomach
D – The patient reported that she has been having this bilateral lower stomach pain for the last two weeks, However, the symptoms got worse since the pain started ago.
C – She stated that since the onset of the pain, her pain has remained constant without any relieve and aggravating factor. The pain is firm regardless of the time or day or event. She further stated that her symptoms get worse. The patient states that she is unaware of what caused the pain or how the pain started; however, she stated that taking pills could relieve her stomach pain and stop her bleeding
A – She stated that the pain remains constant. She also stated that she is unaware of what caused the pain or how the pain started.
R – She stated that the pain remains steady and does not go away or radiate to other areas.
T- she reported feeling uncomfortable doing her regular shores due to the pain.
Past Medical history:
Patient is asthmatic; however, her asthma is under control. She knows known history of any other condition or never been hospitalized.
Family History:
She is the second in a family of four who are all alive and healthy. There is no history of any chronic condition in the family.
Social History:
Patient is a regularly active young woman; she is single and does moderately active exercise. However, she stated that her daily activity and chores has recently reduced due to her recent symptoms of pain. She also stated to have no appetite secondary to her recent pain. She also stated that her stress level may be related with her college. She has no history of alcohol, smoking, or had never smoked in her life. She has not used any ...
1) Naïve T cells have the potential to differentiate into several AbbyWhyte974
1) Naïve T cells have the potential to differentiate into several types of effector cells. In the space below, describe the roles and activities of each of these cells:
TH1 cells
TH2 cells
TH17 cells
TFH cells
2) Use the following diagram to compare and contrast systemic immunity and mucosal immunity.
Systemic
Both Systemic and Mucosal
Mucosal
ordinary surface epithelia
Why is there a need for these differences in the first place?
CDC Sexually Transmitted Diseases Case Study.
Read the patient case study below
General:
The patient is a young seventeen-year-old female who came to the clinic with complaint of abdominal pain.
Chief Complaint:
Kim reports "I've been having pain in my stomach for several weeks." She describes the pain as being sharp and being constant. She stated the pain often occurs on both sides of her lower abdominal. She has been experiencing the pain for the past two weeks. The pain has gotten worse since then.
Reliability and Source of History:
The patient is alert and oriented and able to answer most of the questions.
Source & Reliability of History:
O – "I have been having pain in my stomach for several weeks now.” she stated that the pain has lasted for two weeks without any relief.
L – Both sides of her lower stomach
D – The patient reported that she has been having this bilateral lower stomach pain for the last two weeks, However, the symptoms got worse since the pain started ago.
C – She stated that since the onset of the pain, her pain has remained constant without any relieve and aggravating factor. The pain is firm regardless of the time or day or event. She further stated that her symptoms get worse. The patient states that she is unaware of what caused the pain or how the pain started; however, she stated that taking pills could relieve her stomach pain and stop her bleeding
A – She stated that the pain remains constant. She also stated that she is unaware of what caused the pain or how the pain started.
R – She stated that the pain remains steady and does not go away or radiate to other areas.
T- she reported feeling uncomfortable doing her regular shores due to the pain.
Past Medical history:
Patient is asthmatic; however, her asthma is under control. She knows known history of any other condition or never been hospitalized.
Family History:
She is the second in a family of four who are all alive and healthy. There is no history of any chronic condition in the family.
Social History:
Patient is a regularly active young woman; she is single and does moderately active exercise. However, she stated that her daily activity and chores has recently reduced due to her recent symptoms of pain. She also stated to have no appetite secondary to her recent pain. She also stated that her stress level may be related with her college. She has no history of alcohol, smoking, or had never smoked in her life. She has not used any ...
Soap notes will be uploaded to Moodle and put through TURN-It-In (anWilheminaRossi174
Soap notes will be uploaded to Moodle and put through TURN-It-In (anti-Plagiarism program)
Turn it in Score must be less than 50% or will not be accepted for credit, must be your own work and in your own words. You can resubmit, Final submission will be accepted if less than 50%. Copy paste from websites or textbooks will not be accepted or tolerated. Please see College Handbook with reference to Academic Misconduct Statement.
Example:
PATIENT INFORMATION
Name: Mr. W.S.
Age: 65-year-old
Sex: Male
Source: Patient
Allergies: None
Current Medications: Atorvastatin tab 20 mg, 1-tab PO at bedtime
PMH: Hypercholesterolemia
Immunizations: Influenza last 2018-year, tetanus, and hepatitis A and B 4 years ago.
Surgical History: Appendectomy 47 years ago.
Family History: Father- died 81 does not report information
Mother-alive, 88 years old, Diabetes Mellitus, HTN
Daughter-alive, 34 years old, healthy
Social Hx: No smoking history or illicit drug use, occasional alcoholic beverage consumption on social celebrations. Retired, widow, he lives alone.
SUBJECTIVE:
Chief complain
: “headaches” that started two weeks ago
Symptom analysis/HPI:
The patient is 65 years old male who complaining of episodes of headaches and on 3 different occasions blood pressure was measured, which was high (159/100, 158/98 and 160/100 respectively). Patient noticed the problem started two weeks ago and sometimes it is accompanied by dizziness.He states that he has been under stress in his workplace for the last month.
Patient denies chest pain, palpitation, shortness of breath, nausea or vomiting.
ROS:
CONSTITUTIONAL
: Denies fever or chills. Denies weakness or weight loss.
NEUROLOGIC
: Headache and dizzeness as describe above. Denies changes in LOC. Denies history of tremors or seizures.
HEENT
: HEAD: Denies any head injury, or change in LOC. Eyes: Denies any changes in vision, diplopia or blurred vision. Ear: Denies pain in the ears. Denies loss of hearing or drainage. Nose: Denies nasal drainage, congestion. THROAT: Denies throat or neck pain, hoarseness, difficulty swallowing.
Respiratory
:Patient denies shortness of breath, cough or hemoptysis.
Cardiovascular
: No chest pain, tachycardia. No orthopnea or paroxysmal nocturnal
dyspnea.
Gastrointestinal
:Denies abdominal pain or discomfort.Denies flatulence, nausea, vomiting or
diarrhea.
Genitourinary
: Denies hematuria, dysuria or change in urinary frequency. Denies difficulty starting/stopping stream of urine or incontinence.
MUSCULOSKELETAL
: Denies falls or pain. Denies hearing a clicking or snapping sound.
Skin
: No change of coloration such as cyanosis or jaundice, no rashes or pruritus.
Objective Data
CONSTITUTIONAL
: Vital signs: Temperature: 98.5 °F, Pulse: 87, BP: 159/92 mmhg, RR 20, PO2-98% on room air, Ht- 6’4”, Wt 200 lb, BMI 25. Report pain 0/10.
General appearance: The patient is alert and oriented x 3. No acute distress noted.
NEUROLOGIC:
Alert, CNII-XII grossly intac ...
(Student Name) UniversityDate of EncounterPreceptorCliniMoseStaton39
(Student Name)
University
Date of Encounter:
Preceptor/Clinical Site:
Clinical Instructor:
Soap Note # Main Diagnosis ( Exp: Soap Note #3 DX: Hypertension)
PATIENT INFORMATION
Name: Mr. DT
Age: 68-year-old
Gender at Birth: Male
Gender Identity: Male
Source: Patient
Allergies: PCN, Iodine
Current Medications:
· Atorvastatin tab 20 mg, 1-tab PO at bedtime
· ASA 81mg po daily
· Multi-Vitamin Centrum Silver
PMH: Hypercholesterolemia
Immunizations: Influenza last 2018-year, tetanus, and hepatitis A and B 4 years ago.
Preventive Care: Coloscopy 5 years ago (Negative)
Surgical History: Appendectomy 47 years ago.
Family History: Father- died 81 does not report information
Mother-alive, 88 years old, Diabetes Mellitus, HTN
Daughter-alive, 34 years old, healthy
Social History: No smoking history or illicit drug use, occasional alcoholic beverage consumption on social celebrations. Retired, widow, he lives alone.
Sexual Orientation: Straight
Nutrition History: Diets off and on, Does not each seafood
Subjective Data:
Chief Complaint: “headaches” that started two weeks ago
Symptom analysis/HPI:
The patient is 65 years old male who complaining of episodes of headaches and on 3 different occasions blood pressure was measured, which was high (159/100, 158/98 and 160/100 respectively). Patient noticed the problem started two weeks ago and sometimes it is accompanied by dizziness. He states that he has been under stress in his workplace for the last month. Patient denies chest pain, palpitation, shortness of breath, nausea or vomiting.
Review of Systems (ROS)
CONSTITUTIONAL: Denies fever or chills. Denies weakness or weight loss. NEUROLOGIC: Headache and dizziness as describe above. Denies changes in LOC. Denies history of tremors or seizures.
HEENT: HEAD: Denies any head injury, or change in LOC. Eyes: Denies any changes in vision, diplopia or blurred vision. Ear: Denies pain in the ears. Denies loss of hearing or drainage. Nose: Denies nasal drainage, congestion. THROAT: Denies throat or neck pain, hoarseness, difficulty swallowing.
RESPIRATORY: Patient denies shortness of breath, cough or hemoptysis.
CARDIOVASCULAR: No chest pain, tachycardia. No orthopnea or paroxysmal nocturnal
dyspnea.
GASTROINTESTINAL: Denies abdominal pain or discomfort. Denies flatulence, nausea, vomiting or
diarrhea.
GENITOURINARY: Denies hematuria, dysuria or change in urinary frequency. Denies difficulty starting/stopping stream of urine or incontinence.
MUSCULOSKELETAL: Denies falls or pain. Denies hearing a clicking or snapping sound.
SKIN: No change of coloration such as cyanosis or jaundice, no rashes or pruritus.
Objective Data:
VITAL SIGNS: Temperature: 98.5 °F, Pulse: 87, BP: 159/92 mmhg, RR 20, PO2-98% on room air, Ht- 6’4”, Wt 200 lb, BMI 25. Report pain 2/10.
GENERAL APPREARANCE: The patient is alert and oriented x 3. No acute distress noted. NEUROLOGIC: Alert, CNII-XII grossly intact, oriented to person, ...
(Student Name) UniversityDate of EncounterPreceptorCliniSilvaGraf83
(Student Name)
University
Date of Encounter:
Preceptor/Clinical Site:
Clinical Instructor:
Soap Note # Main Diagnosis ( Exp: Soap Note #3 DX: Hypertension)
PATIENT INFORMATION
Name: Mr. DT
Age: 68-year-old
Gender at Birth: Male
Gender Identity: Male
Source: Patient
Allergies: PCN, Iodine
Current Medications:
· Atorvastatin tab 20 mg, 1-tab PO at bedtime
· ASA 81mg po daily
· Multi-Vitamin Centrum Silver
PMH: Hypercholesterolemia
Immunizations: Influenza last 2018-year, tetanus, and hepatitis A and B 4 years ago.
Preventive Care: Coloscopy 5 years ago (Negative)
Surgical History: Appendectomy 47 years ago.
Family History: Father- died 81 does not report information
Mother-alive, 88 years old, Diabetes Mellitus, HTN
Daughter-alive, 34 years old, healthy
Social History: No smoking history or illicit drug use, occasional alcoholic beverage consumption on social celebrations. Retired, widow, he lives alone.
Sexual Orientation: Straight
Nutrition History: Diets off and on, Does not each seafood
Subjective Data:
Chief Complaint: “headaches” that started two weeks ago
Symptom analysis/HPI:
The patient is 65 years old male who complaining of episodes of headaches and on 3 different occasions blood pressure was measured, which was high (159/100, 158/98 and 160/100 respectively). Patient noticed the problem started two weeks ago and sometimes it is accompanied by dizziness. He states that he has been under stress in his workplace for the last month. Patient denies chest pain, palpitation, shortness of breath, nausea or vomiting.
Review of Systems (ROS)
CONSTITUTIONAL: Denies fever or chills. Denies weakness or weight loss. NEUROLOGIC: Headache and dizziness as describe above. Denies changes in LOC. Denies history of tremors or seizures.
HEENT: HEAD: Denies any head injury, or change in LOC. Eyes: Denies any changes in vision, diplopia or blurred vision. Ear: Denies pain in the ears. Denies loss of hearing or drainage. Nose: Denies nasal drainage, congestion. THROAT: Denies throat or neck pain, hoarseness, difficulty swallowing.
RESPIRATORY: Patient denies shortness of breath, cough or hemoptysis.
CARDIOVASCULAR: No chest pain, tachycardia. No orthopnea or paroxysmal nocturnal
dyspnea.
GASTROINTESTINAL: Denies abdominal pain or discomfort. Denies flatulence, nausea, vomiting or
diarrhea.
GENITOURINARY: Denies hematuria, dysuria or change in urinary frequency. Denies difficulty starting/stopping stream of urine or incontinence.
MUSCULOSKELETAL: Denies falls or pain. Denies hearing a clicking or snapping sound.
SKIN: No change of coloration such as cyanosis or jaundice, no rashes or pruritus.
Objective Data:
VITAL SIGNS: Temperature: 98.5 °F, Pulse: 87, BP: 159/92 mmhg, RR 20, PO2-98% on room air, Ht- 6’4”, Wt 200 lb, BMI 25. Report pain 2/10.
GENERAL APPREARANCE: The patient is alert and oriented x 3. No acute distress noted. NEUROLOGIC: Alert, CNII-XII grossly intact, oriented to person, ...
ABDOMINAL PAIN CASE HISTORY FOR DIAGNOSTIC SYNDROME SLIDESHAREBRINCELET M BIJU
INTRODUCTION
Abdominal pain refers to discomfort that is felt between the chest and the groin.,which can be acute or chronic on presentation.
Categorised into 4 quadrant and 9 regions for analysis of underlying pathologies and their localization ,patient may also present with ;-Bloating, N/V, diarrhea or constipation, fever, visible swelling or tenderness.
It Can occur due to Gastrointestinal pathologies like peptic ulcer ,appendicitis, obstructions, cholecystitis etc or gynecologycal, vascular, peritoneal pathologies
EPIDEMIOLOGY
5 – 10% of all ED visits.
Among them, 14 – 40 % patients need surgical intervention
Most common diagnosis is Non specific
Males were more affected than females with male to female ratio of 1.14 : 1
Highest number of patients were in 15 – 24 years of life
Most common cause found to be acute appendicitis for acute abdomen in a range of 57.5 % of total admission.
CAUSES
Gastrointestinal
Gastrointestinal
Gastroduodenal
Peptic ulcer
Gastritis
Malignancy
Gastric volvulus
Intestinal
Appendicitis
Obstruction
Inverticulitis
Gastroenteritis
Mesentric adenitis
Strangulated hernia
Inflammatory bowel disease
Intussusception
Volvulus
TB
Case
History of Present Illness
A 26-year-old woman comes to the office because of a 3-day history of lower abdominal pain. She is 18 weeks pregnant by dates. The patient describes the pain as sharp, steady, and radiating across her lower abdomen bilaterally. Last night she developed new nausea and vomiting. She has not been able to keep down any food or drink this morning. She had a normal bowel movement yesterday. She says she felt cold and shivering this morning, followed by feeling warm; however, she did not check her temperature. She denies vaginal bleeding.
General: Patient feels generally weak and ill but was in her usual state of health until 3 days ago. She has gained approximately 5 lbs (2.3 kg) in the pregnancy so far.
Skin: She denies rash.
HEENT: Her mouth feels dry. No headache, nasal congestion, or sore throat.
Pulmonary: She denies cough or shortness of breath.
Cardiovascular: She denies chest pain or palpitations.
Gastrointestinal: She has had a decreased appetite for 1 day and has been unable to keep any food or drink down this morning due to nausea and vomiting. She has not had diarrhea or constipation.
Genitourinary: She reports a frequent urge to urinate and a sensation of incomplete bladder emptying for the past 3 days. No dysuria or hematuria. She is G1P0A0 and has been seeing an obstetrician for all routine visits and testing. No vaginal bleeding.
Musculoskeletal: She reports mild diffuse low back pain. No generalized muscle aches.
Neurologic: Noncontributory
Past Medical History
Medical history: Mild intermittent asthma diagnosed in childhood requiring only occasional rescue inhaler use, no hospitalizations for asthma. She is otherwise healthy.
Surgical history: Wisdom teeth removed at age 18.
Medications: Albuterol inhaler as needed, about once a month.
Soap notes will be uploaded to Moodle and put through TURN-It-In (anti.docxhenry34567896
Soap notes will be uploaded to Moodle and put through TURN-It-In (anti-Plagiarism program)
Turn it in Score must be less than 50% or will not be accepted for credit, must be your own work and in your own words. You can resubmit, Final submission will be accepted if less than 50%. Copy paste from
websites
or textbooks will not be accepted or tolerated. Please see College Handbook with reference to Academic Misconduct Statement.
Example:
PATIENT INFORMATION
Name: Mr. W.S.
Age: 65-year-old
Sex: Male
Source: Patient
Allergies: None
Current Medications: Atorvastatin tab 20 mg, 1-tab PO at bedtime
PMH: Hypercholesterolemia
Immunizations: Influenza last 2018-year, tetanus, and hepatitis A and B 4 years ago.
Surgical History: Appendectomy 47 years ago.
Family History: Father- died 81 does not report information
Mother-alive, 88 years old, Diabetes Mellitus, HTN
Daughter-alive, 34 years old, healthy
Social Hx: No smoking history or illicit drug use, occasional alcoholic beverage consumption on social celebrations. Retired, widow, he lives alone.
SUBJECTIVE:
Chief complain
: “headaches†that started two weeks ago
Symptom analysis/HPI:
The patient is 65 years old male who complaining of episodes of headaches and on 3 different occasions blood pressure was measured, which was high (159/100, 158/98 and 160/100 respectively). Patient noticed the problem started two weeks ago and sometimes it is accompanied by dizziness. He states that he has been under stress in his workplace for the last month.
Patient denies chest pain, palpitation, shortness of breath, nausea or vomiting.
ROS:
CONSTITUTIONAL
: Denies fever or chills. Denies weakness or weight loss.
NEUROLOGIC
: Headache and dizziness as describe above. Denies changes in LOC. Denies history of tremors or seizures.
HEENT
: HEAD: Denies any head injury, or change in LOC. Eyes: Denies any changes in vision, diplopia or blurred vision. Ear: Denies pain in the ears. Denies loss of hearing or drainage. Nose: Denies nasal drainage, congestion. THROAT: Denies throat or neck pain, hoarseness, difficulty swallowing.
Respiratory
: Patient denies shortness of breath, cough or hemoptysis.
Cardiovascular
: No chest pain, tachycardia. No orthopnea or paroxysmal nocturnal
dyspnea.
Gastrointestinal
: Denies abdominal pain or discomfort. Denies flatulence, nausea, vomiting or
diarrhea.
Genitourinary
: Denies hematuria, dysuria or change in urinary frequency. Denies difficulty starting/stopping stream of urine or incontinence.
MUSCULOSKELETAL
: Denies falls or pain. Denies hearing a clicking or snapping sound.
Skin
: No change of coloration such as cyanosis or jaundice, no rashes or pruritus.
Objective Data
CONSTITUTIONAL
: Vital signs: Temperature: 98.5 °F, Pulse: 87, BP: 159/92 mmhg, RR 20, PO2-98% on room air, Ht- 6’4â€, Wt 200 lb, BMI 25. Report pain 0/10.
General appearance: The patient is alert and oriented x 3. No acute dist.
Social Media and the Modern Impact of InformaticsWrite an es.docxpbilly1
Social Media and the Modern Impact of Informatics
Write an essay addressing each of the following points/questions. Be sure to completely answer all the questions for each number item. There should be three sections, one for each item number below, as well the introduction (heading is the title of the essay) and conclusion paragraphs. Separate each section in your paper with a clear heading that allows your professor to know which bullet you are addressing in that section of your paper. Support your ideas with at least three (3) scholarly citations using APA citations in your essay. Make sure to reference the citations using the APA writing style for the essay. The cover page and reference page do not count towards the minimum word amount. Review the rubric criteria for this assignment.
Most people remember the story below that made national headlines. As most Americans have smart phones, tablets, and computers the utilization of social media is common place.
Finley, T. (2017, Sept. 20). Navy hospital removes staffers for calling babies ‘mini Satan’s’ on social media.
Parenting
.
If you were writing a hospital policy on smart phone and social media usage, what should be included in the policy?
What potential ethical and legal liabilities are there for the hospital and employees in the case presented above?
In 2007, Harvard University rescinded admission to 10 students after reviewing their social media post.
Do you feel potential employers, current employers, and colleges have the right to access your social media post? Do you feel employers and universities should make decisions based on your post?
Discuss the relationship between accreditation decisions, reimbursement, quality of care, informatics.
.
Social Media and the global marketplace Web 2.0 Business .docxpbilly1
Social Media and the global marketplace: Web 2.0
Business Models
Readings:
Wirtz, B.W., Schilke, O. and Ullrich, S., 2010. Strategic development of
business models: implications of the Web 2.0 for creating value on the
internet. Long Range Planning, 43(2), pp.272-290.
INB 20009 Managing the Global Marketplace
Lesson plan
• Social Media and digital business models
• Socio-cultural research (Verstehen school of thought)
1) Socio-Cultural Research: The social as capital
2) Socio-Cultural Research: The social as theatre
• Stages of Internationalisation
• A Strategic Approach to Internationalisation: A Traditional Versus a
‘Born-Global’ Approach :
• Implications and recommendations
PART 1
CONCEPTS
A BUSINESS MODEL
• The business model is a holistic management
approach that reflects the fundamental value
creation logic, value creation architecture and the
functioning of a company (Timmers 1998).
• A representation of a firm’s underlying core logic and
strategic choices for creating and capturing value
within a value network (Shafer, S.M., Smith, H.J.
and Linder, J.C., 2005 p.202).
A BUSINESS MODEL…contd
• Porter (1985) distinguishes nine value chain elements. Namely, as
primary elements inbound logistics, operations, outbound logistics,
marketing & sales, service; and as support activities technology
development, procurement, human resource management,
corporate infrastructure.
Components of a business model
Source: (Shafer, S.M., Smith, H.J. and Linder, J.C., 2005 p.202).
The 4C-Net-Business-Model typology
(Wirtz 2000; Wirtz and Lihotzky 2003, p. 522)
• A typology to structure the different business
models on the Internet within the B2C sector.
• Four basic business models are characterised
by different service offerings across Content,
Commerce, Context and Connection.
• The classification is considered as 4C-Net-
Business-Model typology (Wirtz 2000, p. 218).
Content, Commerce, Context and
Connection
• Content-orientated business models are used by firms -
such as The Wall Street Journal Online - that focus on
the collection, selection, compilation, distribution, and/or
presentation of online content.
• Their value proposition is to provide convenient, user-
friendly online access to various types of relevant
content.
Content, Commerce, Context and
Connection
• Commerce-orientated business models focus primarily
on the initiation, negotiation, payment and delivery
aspects of trade transactions using online media.
• Commerce-oriented firms, such as Amazon and Dell,
offer cost-efficient transactions for buyers and sellers of
goods and services.
• Companies focusing on this type of business model use
electronic Internet-based processes to substitute or
support traditional transaction functions and arenas,
creating direct revenue streams in the form of sales
revenues, as well as indirect revenue streams such as
commissions.
Content, Commer.
Social Media and the Boston Marathon Bombings A Case StudyB.docxpbilly1
Social Media and the Boston Marathon Bombings: A Case Study
By:
George Haddow and Kim Haddow
, Posted on: June 4, 2015
As we reach the final stretch of the capital trial of the Boston Marathon bomber, we present this case study on social media that was originally published in the author’s book
Disaster Communications in a Changing Media World
:
Case Study: BPD and Social Media
At 2:49 PM on April 15, 2013 two bombs exploded near the finish line of the annual Boston Marathon killing three people and injuring 264. The first reports about the about the terrorist attack were spread through Twitter and Facebook.
At 2:59 PM the
Boston Globe
tweeted:
“BREAKING NEWS: Two powerful explosions detonated in quick succession right next to the Boston Marathon finish line this afternoon.”
Minutes later, the Boston Police Department confirmed the explosion in a tweet. And in a separate tweet soon after reported:
“22 injured. 2 dead
#tweetfromthebeat
via
@CherylFiandaca
”
According to Topsy, a Twitter analytics company, at around 4:10 p.m. there were more than 300,000 mentions on Twitter of “Boston explosions.” (Stern, 2013) In a second wave of social media, details about the event spread. Media that included photos of blood covering the ground and a six-second Vine video of the actual explosion was circulated, deepening people’s sense of what had happened. Around 4:30 p.m., there were more than 700,000 mentions on Twitter of the “Boston Marathon.” (Stern, 2013)
Even though television was the most widely-used source of information about the bombing and its aftermath, it was social media that shaped the story and the response. While 80% of Americans followed the story on TV according to the Pew Research Center, about half (49%) say they kept up with news and information online or on a mobile device and a quarter of Americans got information about the explosions and the hunt for the bombers on social networking sites such as Facebook and Twitter.
Young Americans in particular kept up-to-date through social media. Slightly more than half (56%) of an 18-to-29 year subgroup polled by Pew got bombing-related news through social networking sites. (Pew Research Center, 2013).
The Boston bombings and the manhunt that followed became the backdrop for the world to witness the transformation – for good and for bad — in news gathering and distribution, and in disaster management and crises communications caused by social media platforms and technology. The Boston Marathon bombings were a watershed, a moment that marked forever the changed role of social media and the fully participatory public in breaking news events and coverage. The
New York Times
wrote:
It is America’s first fully interactive national tragedy of the social media age.” (Kakutani, 2013)
From marathon runners giving their accounts on Facebook, to law enforcement officials using Twitter to give real-time updates and asking for help identifying and capturing the suspects, to th.
Social media and adolescence, is it good bad When looking at the c.docxpbilly1
Social media and adolescence, is it good? bad? When looking at the current adolescent generation, social media has become an important influencer. How many likes to I have? How many friends do I have? Am I pretty? etc. are common questions that are asked internally. In this chapter, we were introduced to new thinking patterns and concepts related to this developmental stage, such as personal fable, invincibility fable, egocentrism, etc.
For this assignment, address the following,
How does the influence of social media impact concepts like personal fable, invincibility fable, egocentrism, etc.?
What are the benefits to social media? (think about technology as a whole as well)
How can social media and/or technology hinder development during this stage?
.
Social Media - Public Information OfficerOne of the challeng.docxpbilly1
Social Media - Public Information Officer
One of the challenges facing the Public Information Officer (PIO) is social media. Social media is both a friend and foe of emergency agencies.
1. What is the role and responsibilities of the PIO?
2. And what do Twitter, Facebook, and other social media sites mean these days to the PIO?
3. Using the internet or professional journals,
find two articles and post the links to the two articles
. One of these should show how
an emergency agency uses social media in a positive manner, such as to inform and involve the local community being served.
4. The other link should show
how social media was used in an unprofessional manner and made the agency involved look bad in the eyes of the public.
5. Give a one paragraph summary of each link.
400-450 words excluding reference, APA style format and a minimum of 3 references.
.
Social marketing applies commercial marketing strategies to promot.docxpbilly1
Social marketing applies commercial marketing strategies to promote public health.
Social marketing is widely used to influence health behavior. Social marketers use a wide range of health communication strategies based on mass media, they also use mediated (example, through a healthcare provider), interpersonal, and other modes of communication, and marketing methods such as message placement (for example, in clinics), promotion, dissemination, and community level outreach. Social marketing encompasses all of these strategies.
Courtesy: NIH
Application of social marketing strategies for measles, mumps and rubella (MMR) vaccination. in young children’s. People in many developing countries have misgivings, fear and other reasons against MMR vaccination resulting in resurgence or disease epidemics. Social marketing theory work well in countering these obstacles while encouraging administration of the vaccine to improve the health of the society.
Concepts-
1. Consumer orientation- In this approach planning, implementation and evaluation strategies of consumer marketing is employed to motivate the parents for vaccination of their children’s against MMR. We took advice from people to what change we make to adopt this healthy behavior. Needs assessment this message is appropriate from them what barrier environment we have to take. Also take care how people respond to the healthy behavior. Citizen advisory panels help to get feedback.
2. Audience segmentation- . Parents of the children are selected that largely influences the success of MMR vaccination in the children. Positive behavior change to vaccinate their children is encouraged by educating them and creating awareness about the complications associated with MMR viral epidemics. We target the group which have similar variable and advise them.
3. Channel analysis- Method to deliver the required message and the desired place to target the population/desired audience (parents). Usage of print ,news and online social media to convey the benefits and the risks associated with vaccinating and not vaccinating with MMR Other places that can be targeted are gynecologic and pediatrics hospitals while utilizing other public places with posters to spread the awareness and the benefits of MMR. We also have to find appropriate time when to advertise and advice these desired population.
4. Strategy- In this stage of planning the idea is to meet the objectives. We can use different strategies like making the vaccine available in every hospital facility for easy access, making vaccine cost effective to eliminate the barriers of our target population.
5. Process tracking- In this evaluation phase of the program we check and monitor if the applied interventions are rightly executed to achieve the objectives. After undertaking surveys, reviewing and revisiting the steps, progress can be tracked. We can also obtain feedback from the target population to improve and enhance the performance of the pr.
Social Justice and Family Policy Dr. Williams Instructi.docxpbilly1
Social Justice and Family Policy
Dr. Williams
Instructions for the Critical Essay
Utilizing seven to ten outside scholarly sources students are to write critical essays (5-7 pages not
including title and reference pages) documenting an essential issue with regard to the course’s influence
on a policy. Students may also include official and organizational research reports as part of their
allotted references too1. These essays are positional in nature (you’re arguing a stance using scholarly
evidence), and will be written in an academic and scholarly tone. Arguments must be cogent, logical,
and supported by facts (which will come from one’s research). APA citation and reference lists are
required. These essays will be well proof-read before submission. Font: Times New Roman, 12. The
essay should be double-spaced and numbered. Below are instructions regarding the format:
1. The assignment requires a traditional APA title page. Students may assign the essay its own
title, be creative. Again, the title page and references are not counted in the page requirement.
2. The structure of the paper should be sectioned like such:
a. Introduction
b. The Policy (here you will provide an explanation/background of your chosen policy)
c. Corresponding Issue #1
d. Corresponding Issue #2
e. Suggested Policy Change
f. Conclusion
g. References
3. The Introduction should provide a thorough roadmap of where you intend to take the reader;
thus, here you want to establish a clear but brief outline of your policy of choice and the issues
you plan to uncover—leave the rest for folks to see in the essay. This should be no more than a
good thick paragraph.
4. The proceeding pages should be well structured by sections/headings which will correspond to
remaining four points mentioned after the introduction. For example, for a policy one may
choose sentencing, and then his/her two issues may be mass incarceration and reentry (you’d
use those titles as the headings for your sections in the essay, or you can be more creative and
call them something else, but the sections need to be distinct from each other). The
information contained in each respective section will include a meshing together of your
scholarly sources and your understanding of your chosen policy. This part of the essay will
become more refined as one continue to engage in research. Remember, all points/arguments
explained in these pages must be cited and backed by evidence. Your writing should be both
informative and persuasive, which means you should be explaining to your reader the gist of the
1. These are the sources that will give one the statistics he/she would need to describe the scope of the
problem/issue which will be covered in the essay. It is important that the essay has some stats in it to substantiate
all arguments. For instance, for crime stats see .
SOCIAL JUSTICE AND SOCIOLOGYAGENDAS FOR THETWENTY-FIR.docxpbilly1
SOCIAL JUSTICE AND SOCIOLOGY:
AGENDAS FOR THE
TWENTY-FIRST CENTURY
JOE R, FEAGIN
University of Florida
The world's peoples face daunting challenges in the
twenty-first century. While apologists herald the globaliza-
tion of capitalism, many people on our planet experience
recurring economic exploitation, immiseration, and envi-
ronmental crises linked to capitalism's spread. Across the
globe social movements continue to raise the issues of
social justice and democracy. Given the new century's
serious challenges, sociologists need to rediscover their
roots in a sociology committed to social justice, to cultivate and extend the long-
standing "countersystem" approach to research, to encourage greater self-reflection
in sociological analysis, and to re-emphasize the importance ofthe teaching of soci-
ology. Finally, more sociologists should examine the big social questions of this
century, including the issues of economic exploitation, social oppression, and the
looming environmental crises. And, clearly, more sociologists should engage in the
study of alternative social futures, including those of more just and egalitarian soci-
eties. Sociologists need to think deeply and imaginatively about sustainable social
futures and to aid in building better human societies.
WE STAND today at the beginning ofa challenging new century. Like
ASA Presidents before me, I am conscious
of the honor and the responsibility that this
address carries with it, and I feel a special
obligation to speak about the role of sociol-
ogy and sociologists in the twenty-first cen-
tury. As we look forward, let me quote W. E.
B. Du Bois, a pathbreaking U.S. sociologist.
In his last autobiographical statement, Du
Bois (1968) wrote:
Direct correspondence to Joe R. Feagin, De-
partment of Sociology, Box 117330, University
of Florida, Gainesville, FL 32611, (feagin®
ufl.edu). I would like to thank the numerous col-
leagues who made helpful comments on various
drafts of this presidential address. Among these
were Hernan Vera, Sidney Willhelm, Bernice
McNair Barnett, Gideon Sjoherg, Anne Rawls,
Mary Jo Deegan, Michael R. Hill, Patricia
Lengermann, Jill Niebrugge-Brantley, Tony
Orum, William A. Smith, Ben Agger, Karen
Pyke, and Leslie Houts.
[TJoday the contradictions of American civi-
lization are tremendous. Freedom of politi-
cal discussion is difficult; elections are not
free and fair. . . . The greatest power in the
land is not thought or ethics, but wealth. . . .
Present profit is valued higher than future
need. . . . I know the United States. It is my
country and the land of my fathers. It is still
a land of magnificent possibilities. It is still
the home of noble souls and generous
people. But it is selling its birthright. It is
betraying its mighty destiny. (Pp. 418-19)
Today the social contradictions of Ameri-
can and global civilizations are still im-
mense. Many prominent voices tell us that it
is the best of times; other voices insist that it
is the worst of t.
Social Justice Analysis of a Current Issue The effects of the O.docxpbilly1
Social Justice Analysis of a Current Issue: The effects of the Opioid Epidemic in urban communities
the most recent edition of the APA manual).
In 3-4 pages, title and references apply course frameworks to a contentious current social welfare policy issue
.
Social issue - BullyingIdentify and summarize the contemporary s.docxpbilly1
Social issue - Bullying
Identify and summarize the contemporary social issue you selected (Bullying), citing resources to strengthen your summary. Explain what is happening in the issue, and provide a brief history of how the issue began.
**See the attached file for additional questions and instructions on how to answer the questions using PowerPoint **
.
Social InterestA key component of Adlers theory is what he call.docxpbilly1
Social Interest
A key component of Adler's theory is what he calls "social interest." He maintains that social interest is an important criterion for a healthy personality. Adler also talks about inferiority and compensation in his theory of personality.
On the basis of your understanding on "social interest," discuss the following:
Write about a public figure from popular culture, such as politics, movies, or television.
Explain how social interest is or was a factor in his or her personality development.
Explain how factors such as inferiority and compensation are displayed in your subject's personality.
Support your responses with examples. Cite any sources in APA format.
.
Social Interaction AssignmentPurpose To research a social.docxpbilly1
Social Interaction Assignment
Purpose:
To research a social setting and observe social interaction.
Instructions:
Visit an area where you can discretely observe social interaction (i.e., a cafeteria, a restaurant, the mall, a social event, etc.) and complete the summary and analysis below. Before conducting your observation, review the following concepts from your text:
Review the symbolic interaction approach (pages 20-22)
Chapter 5: Socialization
Chapter 6: Social Interaction in Everyday Life
The Activity:
Spend some time (minimum of 15 minutes) quietly observing what is going on and briefly summarize what different persons in the setting were doing.
Summary and Analysis:
Once you have completed your observation and made notes, analyze the patterns of social interaction that you observed and respond to the following:
1) Describe the context for your observation. This includes the location, setting, type of people observed, time of day, day of week length of observation, etc. You may also include any other details you deem relevant.
2) What examples of socialization did you notice? This may include the process of socialization in progress (i.e. a parent encouraging their child to use good table manners) or evidence of the effects of socialization (i.e. waiting politely in a long line).
3) Give at least three examples of each of the following that you observed during your interaction: ascribed status, achieved status, and roles.
4) Describe at least five examples of social exchange that you noticed and discuss the potential impact (helpful, disruptive, etc.) on the individuals involved.
5) What examples of “gendered” interaction did you notice regarding the ways in which women and men are socialized regarding demeanor, uses of space, starting, touching, smiling, and language. Explain whether or not this was consistent with what you learned in chapter 6 (pages 165-166 and 170).
Mechanics:
Assignments must be a minimum of one page, single spaced, typed, standard 8.5x11 page, 1” margins, Times New Roman or Arial 10-12 point font, and include your name/course/assignment title/date.
.
Social Institutions are a part of our everyday life. What is a socia.docxpbilly1
Social Institutions are a part of our everyday life. What is a social institution? How do social institutions effect your life? Write a one-page paper about the micro and macro implications of social institutions that you have read about in this module. What theoretical implications can you uncover? Why do you think it is important to study social institutions?
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Social Institutions Paper#2 topic is one of those below .docxpbilly1
Social Institutions
Paper#2 topic is one of those below
1. Economy (Topic: Feminization of Poverty)
2. Education (Topics: Inequality (individual and /or structural) or School Violence)
3. The Elderly (Topics: Ageism/Discrimination or Elder Abuse)
.
Social InjusticeInstructionsPlease complete the following s.docxpbilly1
Social Injustice
Instructions:
Please complete the following steps for your discussion post.
After you have completed the Unit 6 material and have considered the many different roles and effects of popular culture, consider the following questions:
What has been pop culture’s role in promoting social justice? Give specific examples.
Share one unique example (that has not been mentioned in the unit or by classmates) or how pop culture has promoted social justice, awareness of an issue, or has had a role in influencing public opinion to promote equality, justice, acceptance or tolerance.
In your opinion, do people with a large pop culture following have an ethical responsibility to promote positive messages in their work?
Please be sure to validate your opinions and ideas with citations and references in APA format.
.
Social injustice in educationincluded in my PowerPoint was 1.docxpbilly1
Social injustice in education
included in my PowerPoint was
1. How education affect children poverty
2. how immigrants struggle in education and their mental health
3. LGBTQ how they struggle in education and their mental health
4. The discipline in school like certain rules that are in placed that affect them
needs to be 6 pages and I need at least four references
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Social Injustice, Jack Johnson, pro boxer how did racism influen.docxpbilly1
Social Injustice,
Jack Johnson, pro boxer how did racism influence his professional life.
Muhammad Ali, how did his refusal to go into the army affect his professional career.
Tommy Smith, what happened to him after coming home from the Olympics at the raising his fist.
LeBron James, what has been his influence in today’s society when it pertains to social injustices.
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Social influence is not always negative. In some instances, it may.docxpbilly1
Social influence is not always negative. In some instances, it may be used to promote beneficial behaviors. Are the decisions made by individuals in response to positive social influences more valid than those made in response to negative social influences? Why or why not? [Provide 2 references and 2 intext citations]
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We all have good and bad thoughts from time to time and situation to situation. We are bombarded daily with spiraling thoughts(both negative and positive) creating all-consuming feel , making us difficult to manage with associated suffering. Good thoughts are like our Mob Signal (Positive thought) amidst noise(negative thought) in the atmosphere. Negative thoughts like noise outweigh positive thoughts. These thoughts often create unwanted confusion, trouble, stress and frustration in our mind as well as chaos in our physical world. Negative thoughts are also known as “distorted thinking”.
How to Split Bills in the Odoo 17 POS ModuleCeline George
Bills have a main role in point of sale procedure. It will help to track sales, handling payments and giving receipts to customers. Bill splitting also has an important role in POS. For example, If some friends come together for dinner and if they want to divide the bill then it is possible by POS bill splitting. This slide will show how to split bills in odoo 17 POS.
Model Attribute Check Company Auto PropertyCeline George
In Odoo, the multi-company feature allows you to manage multiple companies within a single Odoo database instance. Each company can have its own configurations while still sharing common resources such as products, customers, and suppliers.
Students, digital devices and success - Andreas Schleicher - 27 May 2024..pptxEduSkills OECD
Andreas Schleicher presents at the OECD webinar ‘Digital devices in schools: detrimental distraction or secret to success?’ on 27 May 2024. The presentation was based on findings from PISA 2022 results and the webinar helped launch the PISA in Focus ‘Managing screen time: How to protect and equip students against distraction’ https://www.oecd-ilibrary.org/education/managing-screen-time_7c225af4-en and the OECD Education Policy Perspective ‘Students, digital devices and success’ can be found here - https://oe.cd/il/5yV
The Indian economy is classified into different sectors to simplify the analysis and understanding of economic activities. For Class 10, it's essential to grasp the sectors of the Indian economy, understand their characteristics, and recognize their importance. This guide will provide detailed notes on the Sectors of the Indian Economy Class 10, using specific long-tail keywords to enhance comprehension.
For more information, visit-www.vavaclasses.com
The Roman Empire A Historical Colossus.pdfkaushalkr1407
The Roman Empire, a vast and enduring power, stands as one of history's most remarkable civilizations, leaving an indelible imprint on the world. It emerged from the Roman Republic, transitioning into an imperial powerhouse under the leadership of Augustus Caesar in 27 BCE. This transformation marked the beginning of an era defined by unprecedented territorial expansion, architectural marvels, and profound cultural influence.
The empire's roots lie in the city of Rome, founded, according to legend, by Romulus in 753 BCE. Over centuries, Rome evolved from a small settlement to a formidable republic, characterized by a complex political system with elected officials and checks on power. However, internal strife, class conflicts, and military ambitions paved the way for the end of the Republic. Julius Caesar’s dictatorship and subsequent assassination in 44 BCE created a power vacuum, leading to a civil war. Octavian, later Augustus, emerged victorious, heralding the Roman Empire’s birth.
Under Augustus, the empire experienced the Pax Romana, a 200-year period of relative peace and stability. Augustus reformed the military, established efficient administrative systems, and initiated grand construction projects. The empire's borders expanded, encompassing territories from Britain to Egypt and from Spain to the Euphrates. Roman legions, renowned for their discipline and engineering prowess, secured and maintained these vast territories, building roads, fortifications, and cities that facilitated control and integration.
The Roman Empire’s society was hierarchical, with a rigid class system. At the top were the patricians, wealthy elites who held significant political power. Below them were the plebeians, free citizens with limited political influence, and the vast numbers of slaves who formed the backbone of the economy. The family unit was central, governed by the paterfamilias, the male head who held absolute authority.
Culturally, the Romans were eclectic, absorbing and adapting elements from the civilizations they encountered, particularly the Greeks. Roman art, literature, and philosophy reflected this synthesis, creating a rich cultural tapestry. Latin, the Roman language, became the lingua franca of the Western world, influencing numerous modern languages.
Roman architecture and engineering achievements were monumental. They perfected the arch, vault, and dome, constructing enduring structures like the Colosseum, Pantheon, and aqueducts. These engineering marvels not only showcased Roman ingenuity but also served practical purposes, from public entertainment to water supply.
Read| The latest issue of The Challenger is here! We are thrilled to announce that our school paper has qualified for the NATIONAL SCHOOLS PRESS CONFERENCE (NSPC) 2024. Thank you for your unwavering support and trust. Dive into the stories that made us stand out!
SOAP NOTE SAMPLE FORMAT FOR MRCName LPDateTime 1315.docx
1. 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.
2. 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
3. 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 any kind
Gastrointestinal
Abdominal pain (see HPI) and Hx of GERD. Denies N/V/D,
constipation, appetite changes
Ears
Denies Ear pain, hearing loss, ringing in ears
Genitourinary/Gynecological
Reports burning with urination, but denies frequency or
urgency. Contraceptive and STD prevention includes condoms
with every coital event. Current stable sexual relationship with
one man. Denies known historic or recent STD exposure. Last
PAP was 7/2016 and normal. Regular monthly menstrual cycle
lasting 3-4 days.
Nose/Mouth/Throat
Denies sinus problems, dysphagia, nose bleeds or discharge
4. Musculoskeletal
Denies back pain, joint swelling, stiffness or pain
Breast
Denies SBE
Neurological
Denies syncope, seizures, paralysis, weakness
Heme/Lymph/Endo
Denies bruising, night sweats, swollen glands
Psychiatric
Denies depression, anxiety, sleeping difficulties
OBJECTIVE
Weight 140lb
Temp -97.7
BP 123/82
Height 5’4”
Pulse 74
Respiration 18
General Appearance
Healthy appearing adult female in no acute distress. Alert and
oriented; answers questions appropriately.
Skin
Skin is normal color for ethnicity, warm, dry, clean and intact.
No rashes or lesions noted.
HEENT
Head is norm cephalic, hair evenly distributed. Neck: Supple.
Full ROM. Teeth are in good repair.
Cardiovascular
S1, S2 with regular rate and rhythm. No extra heart sounds.
Respiratory
Symmetric chest walls. Respirations regular and easy; lungs
clear to auscultation bilaterally.
Gastrointestinal
Abdomen flat; BS active in all 4 quadrants. Abdomen soft,
suprapubic tender. No hepatosplenomegaly.
Genitourinary
5. Suprapubic tenderness noted. Skin color normal for ethnicity.
Irritation noted at labia majora, minora, and perineum. No
ulcerated lesions noted. Lymph nodes not palpable. Vagina
pink and moist without lesions. Discharge minimal, thick, dark
red, no odor. Cervix pink without lesions. No CMT. Uterus
normal size, shape, and consistency.
Musculoskeletal
Full ROM seen in all 4 extremities as patient moved about the
exam room.
Neurological
Speech clear. Good tone. Posture erect. Balance stable; gait
normal.
Psychiatric
Alert and oriented. Dressed in clean clothes. Maintains eye
contact. Answers questions appropriately.
Lab Tests
Urinalysis – blood noted (pt. on menstrual period), but results
negative for infection
Urine culture testing unavailable
Wet prep - inconclusive
STD testing pending for gonorrhea, chlamydia, syphilis, HIV,
HSV 1 & 2, Hep B & C
Special Tests- No ordered at this time.
Diagnosis
Differential Diagnoses
· 1-Bacterial Vaginosis (N76.0)
· 2- Malignant neoplasm of female genital organ, unspecified.
(C57.9)
· 3-Gonococcal infection, unspecified. (A54.9)
Diagnosis
· Urinary tract infection, site not specified. (N39.0) Candidiasis
of vulva and vagina. (B37.3) secondary to presenting symptoms
(Colgan & Williams, 2011) & (Hainer & Gibson, 2011).
6. Plan/Therapeutics
· Plan:
· Medication –
· Terconazole cream 1 vaginal application QHS for 7 days for
Vulvovaginal Candidiasis;
· Sulfamethoxazole/TMP DS 1 tablet PO twice daily for 3 days
for UTI (Woo & Wynne, 2012)
· Education –
· Medications prescribed.
· UTI and Candidiasis symptoms, causes, risks, treatment,
prevention. Reasons to seek emergent care, including N/V,
fever, or back pain.
· STD risks and preventions.
· Ulcer prevention, including taking Protonix as prescribed, not
exceeding the recommended dose limit of NSAIDs, and not
taking NSAIDs on an empty stomach.
· Follow-up –
· Pt will be contacted with results of STD studies.
· Return to clinic when finished the period for perform pap-
smear or if symptoms do not resolve with prescribed TX.
References
Colgan, R. & Williams, M. (2011). Diagnosis and Treatment of
Acute Uncomplicated Cystitis. American Family Physician,
84(7), 771-776.
Hainer, B. & Gibson, M. (2011). Vaginitis: Diagnosis and
Treatment. American Family Physician, 83(7), 807-815.
Woo, T. M., & Wynne, A. L. (2012). Pharmacotherapeutics for
Nurse Practitioner Prescribers (3rd ed.). Philadelphia, PA: F.A.
Davis Company.
PATIENT INFORMATION
Name: Mr. W.S.
7. Age: 65-year-old
Sex: Male
Source: Patient
Allergies: None
Current Medications: Atorvastatin tab 20 mg, 1-tab PO at
bedtime
PMH: Hypercholesterolemia
Immunizations: Influenza last 2018-year, tetanus, and hepatitis
A and B 4 years ago.
Surgical History: Appendectomy 47 years ago.
Family History: Father- died 81 does not report information
Mother-alive, 88 years old, Diabetes Mellitus,
HTN
Daughter-alive, 34 years old, healthy
Social Hx: No smoking history or illicit drug use, occasional
alcoholic beverage consumption on social celebrations. Retired,
widow, he lives alone.
SUBJECTIVE:
Chief complain: “headaches” that started two weeks ago
Symptom analysis/HPI:
The patient is 65 years old male who complaining of episodes of
headaches and on 3 different occasions blood pressure was
measured, which was high (159/100, 158/98 and 160/100
respectively). Patient noticed the problem started two weeks ago
and sometimes it is accompanied by dizziness. He states that he
has been under stress in his workplace for the last month.
Patient denies chest pain, palpitation, shortness of breath,
nausea or vomiting.
ROS:
CONSTITUTIONAL: Denies fever or chills. Denies weakness or
weight loss. NEUROLOGIC: Headache and dizzeness as
describe above. Denies changes in LOC. Denies history of
tremors or seizures.
HEENT: HEAD: Denies any head injury, or change in LOC.
Eyes: Denies any changes in vision, diplopia or blurred vision.
8. Ear: Denies pain in the ears. Denies loss of hearing or drainage.
Nose: Denies nasal drainage, congestion. THROAT: Denies
throat or neck pain, hoarseness, difficulty swallowing.
Respiratory: Patient denies shortness of breath, cough or
hemoptysis.
Cardiovascular: No chest pain, tachycardia. No orthopnea or
paroxysmal nocturnal
dyspnea.
Gastrointestinal: Denies abdominal pain or discomfort. Denies
flatulence, nausea, vomiting or
diarrhea.
Genitourinary: Denies hematuria, dysuria or change in urinary
frequency. Denies difficulty starting/stopping stream of urine or
incontinence.
MUSCULOSKELETAL: Denies falls or pain. Denies hearing a
clicking or snapping sound.
Skin: No change of coloration such as cyanosis or jaundice, no
rashes or pruritus.
Objective Data
CONSTITUTIONAL: Vital signs: Temperature: 98.5 °F, Pulse:
87, BP: 159/92 mmhg, RR 20, PO2-98% on room air, Ht- 6’4”,
Wt 200 lb, BMI 25. Report pain 0/10.
General appearance: The patient is alert and oriented x 3. No
acute distress noted. NEUROLOGIC: Alert, CNII-XII grossly
intact, oriented to person, place, and time. Sensation intact to
bilateral upper and lower extremities. Bilateral UE/LE strength
5/5.
HEENT: Head: Normocephalic, atraumatic, symmetric, non-
tender. Maxillary sinuses no tenderness. Eyes: No conjunctival
injection, no icterus, visual acuity and extraocular eye
movements intact. No nystagmus noted. Ears: Bilateral canals
patent without erythema, edema, or exudate. Bilateral tympanic
membranes intact, pearly gray with sharp cone of light.
Maxillary sinuses no tenderness. Nasal mucosa moist without
bleeding. Oral mucosa moist without lesions,.Lids non-
remarkable and appropriate for race.
9. Neck: supple without cervical lymphadenopathy, no jugular vein
distention, no thyroid swelling or masses.
Cardiovascular: S1S2, regular rate and rhythm, no murmur or
gallop noted. Capillary refill < 2 sec.
Respiratory: No dyspnea or use of accessory muscles observed.
No egophony, whispered pectoriloquy or tactile fremitus on
palpation. Breath sounds presents and clear bilaterally on
auscultation.
Gastrointestinal: No mass or hernia observed. Upon
auscultation, bowel sounds present in all four quadrants, no
bruits over renal and aorta arteries. Abdomen soft non-tender,
no guarding, no rebound no distention or organomegaly noted
on palpation
Musculoskeletal: No pain to palpation. Active and passive ROM
within normal limits, no stiffness.
Integumentary: intact, no lesions or rashes, no cyanosis or
jaundice.
Assessment
Essential (Primary) Hypertension (ICD10 I10): Given the
symptoms and high blood pressure (156/92 mmhg), classified as
stage 2. Once the organic cause of hypertension has been ruled
out, such as renal, adrenal or thyroid, this diagnosis is
confirmed.
Differential diagnosis:
· Renal artery stenosis (ICD10 I70.1)
· Chronic kidney disease (ICD10 I12.9)
· Hyperthyroidism (ICD10 E05.90)
Plan
Diagnosis is based on the clinical evaluation through history,
physical examination, and routine laboratory tests to assess risk
factors, reveal identifiable causes and detect target-organ
damage, including evidence of cardiovascular disease.
These basic laboratory tests are:
· CMP
10. · Complete blood count
· Lipid profile
· Thyroid-stimulating hormone
· Urinalysis
· Electrocardiogram
· Pharmacological treatment:
The treatment of choice in this case would be:
Thiazide-like diuretic and/or a CCB
· Hydrochlorothiazide tab 25 mg, Initial dose: 25 mg orally
once daily.
· Non-Pharmacologic treatment:
· Weight loss
· Healthy diet (DASH dietary pattern): Diet rich in fruits,
vegetables, whole grains, and low-fat dairy products with
reduced content of saturated and trans l fat
· Reduced intake of dietary sodium: <1,500 mg/d is optimal
goal but at least 1,000 mg/d reduction in most adults
· Enhanced intake of dietary potassium
· Regular physical activity (Aerobic): 90–150 min/wk
· Tobacco cessation
· Measures to release stress and effective coping mechanisms.
Education
· Provide with nutrition/dietary information.
· Daily blood pressure monitoring at home twice a day for 7
days, keep a record, bring the record on the next visit with her
PCP
· Instruction about medication intake compliance.
· Education of possible complications such as stroke, heart
attack, and other problems.
· Patient was educated on course of hypertension, as well as
warning signs and symptoms, which could indicate the need to
attend the E.R/U.C. Answered all pt. questions/concerns. Pt
verbalizes understanding to all
Follow-ups/Referrals
11. · Evaluation with PCP in 1 weeks for managing blood pressure
and to evaluate current hypotensive therapy. Urgent Care visit
prn.
· No referrals needed at this time.
References
Domino, F., Baldor, R., Golding, J., Stephens, M. (2017). The
5-Minute Clinical Consult 2017 (25th ed.). Print (The 5-Minute
Consult Series).
Codina Leik, M. T. (2014). Family Nurse Practitioner
Certification Intensive Review (2nd ed.). ISBN 978-0-8261-
3424-0