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.
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 ...
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.
(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, ...
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 ...
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.
(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, ...
(Student Name)Miami Regional UniversityDate of EncounterP.docxgertrudebellgrove
(Student Name)
Miami Regional University
Date of Encounter:
Preceptor/Clinical Site:
Clinical Instructor:
Soap Note # Main Diagnosis Diabetes Mellitus type 2
PATIENT INFORMATION
Name: Mr. ET
Age: 56-year-old
Gender at Birth: Female
Gender Identity: Female
Source: Patient
Allergies: Penicillins
Current Medications:
· Multi-Vitamin Centrum Silver
· Lisinopril 10 mg daily
· PMH: HTN
Diabetes mellitus type 2
Immunizations:
Preventive Care: Coloscopy 3 years ago (Negative)
Surgical History: laparoscopic cholecystectomy
Family History: Father alive
Mother-alive, 90 years old, Diabetes Mellitus, HTN
Daughter-alive, 21 years old, healthy
Social History: No smoking history or illicit drug use, occasional alcoholic beverage consumption on social celebrations. Retired, widow, she lives alone.
Sexual Orientation: Straight
Nutrition History: Diets off and on
Subjective Data:
Chief Complaint: “I cannot stop to drink water and to pee, I need to see my labs”
Symptom analysis/HPI:
The patient is 56 years old female who complaining of she cannot stop to drink water and to pee. Patient noticed the problem started 1 month ago and sometimes it is accompanied by anxious for eat. She states that she has been under stress because her daughter for the last month. Patient denies pain, or another symptom. She makes some labs and coming to see the results.
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 and Lab valuesTemperature: 97.5 °F, Pulse: 84, BP: 142/82 mmhg, RR 20, PO2-98% on room air, Ht- fill, Wt fill lb, BMI 37.2. No report pain 0/10.
HbA1C 9.5 %.
Serum creatinine 1.2 mg/dl, add more
GENERAL APPREARANCE: 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.
HE.
(Student Name)Miami Regional UniversityDate of EncounterP.docxgertrudebellgrove
(Student Name)
Miami Regional University
Date of Encounter:
Preceptor/Clinical Site:
Clinical Instructor:
Soap Note # Main Diagnosis Diabetes Mellitus type 2
PATIENT INFORMATION
Name: Mr. ET
Age: 56-year-old
Gender at Birth: Female
Gender Identity: Female
Source: Patient
Allergies: Penicillins
Current Medications:
· Multi-Vitamin Centrum Silver
· Lisinopril 10 mg daily
· PMH: HTN
Diabetes mellitus type 2
Immunizations:
Preventive Care: Coloscopy 3 years ago (Negative)
Surgical History: laparoscopic cholecystectomy
Family History: Father alive
Mother-alive, 90 years old, Diabetes Mellitus, HTN
Daughter-alive, 21 years old, healthy
Social History: No smoking history or illicit drug use, occasional alcoholic beverage consumption on social celebrations. Retired, widow, she lives alone.
Sexual Orientation: Straight
Nutrition History: Diets off and on
Subjective Data:
Chief Complaint: “I cannot stop to drink water and to pee, I need to see my labs”
Symptom analysis/HPI:
The patient is 56 years old female who complaining of she cannot stop to drink water and to pee. Patient noticed the problem started 1 month ago and sometimes it is accompanied by anxious for eat. She states that she has been under stress because her daughter for the last month. Patient denies pain, or another symptom. She makes some labs and coming to see the results.
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 and Lab valuesTemperature: 97.5 °F, Pulse: 84, BP: 142/82 mmhg, RR 20, PO2-98% on room air, Ht- fill, Wt fill lb, BMI 37.2. No report pain 0/10.
HbA1C 9.5 %.
Serum creatinine 1.2 mg/dl, add more
GENERAL APPREARANCE: 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.
HE ...
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
.
PATIENT INFORMATIONName Mr. W.S.Age 65-year-oldSex Male.docxJUST36
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 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 membrane.
Clinical Documentation Template
Subjective
Chief Complaint: 52 year old male present for three month follow and labs check.
HPI: A 52-year old male with PMH of Hyperlipidemia diabetes presents to the clinic for three month follow up. Patient complained of polyuria, polydipsia and polyphasia. Patient is presently taking plavix and sexagliptin. Patient denies any chest pain, fever and chills.
ROS
General: lost 15lbs in last one month, admit weakness, fatigue. Denies depression, suicide throught.
Skin: no rashes, no open wound..
Head: Denies headache, head injury, dizziness.
Eyes: no vision change, corrective lenses, pain redness, excessive tearing, double vision, blurred
vision, or blindness.
Ears: no hearing change, tinnitus, infection, discharge.
Nose/Sinus: negative for Rhinohea, No sinus pain or epistaxis.
Throat: No bleeding gums, dentures, sore tongue,dry mouth. Last dental exam 4 months ago.
Neck: No lumps, swollen glands, goiter, pain, or neck stiffness.
Neuro: experience syncope once a week, denies seizures, weakness, paralysis, numbness/tingling, tremors, or involuntary movements.
Pulmonary: negative hemoptysis, dyspnea, wheezing,pleuritic pain
Peripheral vascular: no claudication, leg cramps, varicose veins, history of blood clots,
abdominal, flank, or back pain. Pain in arms or legs. Intermittent claudication, cold, numbness,
pallor legs. Swelling in calves, legs, or feet. No color change in fingertips or toes in cold weather.
Swelling with redness or tenderness.
MS: no muscle, joint pain, or joint stiffness.
GI: No changes in appetite, excessive hunger or thirst, jaundice, N/V, dysphagia, heartburn, pain,
belching/flatulence, change in bowel habits, hematochezia, melena, constipation, diarrhea, food
intolerance, indigestion, nausea, vomiting, early fullness, odynophagia.
GU: No suprapubic pain, dysuria, urgency, frequency, hesitancy, decreased stream, polyuria,
nocturia, incontinence, hematuria, kidney, or flank pain, ureteral colic, hemorrhoids.
O:
Past Medical History: Hyperlipidemia, diabetes
Surgeries: Appendectomy, 2000
Hospitalizations: 2000 (for appendectomy)
Allergies: NKDA
Food, drug, environmental: None
Medications: Plavix 75 mg daily (prescribed by his PCP in INDIA as a prophylaxis to prevent Heart attack. We use Aspirin 81 mg here in USA)
Sexagliptin 5 mg daily
Family History: Gout (Father)
Diabetes (Mother)
.
Social History: Denies tobacco/e-cigarette and alcohol use.
Objective
Vital Signs: Temp 98.2 BP 128/90 Pulse 64 RR 18 Pain 0 Height 5’ 8” Weight 140 lb BMI 21.3 SpO2 97% @ RA
Labs: Lipid Panel
Cholesterol 272 mg/dl
Triglyceride 175 mg/dl
HDL 28 mg/dl
LDL 135 mg/dl
HgA1c 9.8%
Physical Exam:
HEENT:
Head: hair normal texture and distribution, no lumps/bumps/lesions noted to scalp. Scalp/skull non-tender with palpation. Skull normocephalic/atraumati.
SOAP NOTE SAMPLE FORMAT FOR MRCName LPDateTime 1315.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 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.
Clinical Documentation Template
Student: Deepak Sharma Site: Elgin Medical Ctr
Client’s Initials: MS Age : 64 Gender : Male Date: 04/07/2019
Subjective
Chief Complaint: 64 year old Hispanic male present to the clinic with chest discomfort.
HPI: Mr. JG. is a 64-year old male with a history of HTN and dyslipidemia present to the clinic with chest discomfort for past two month. Patient stated that chest discomfort is in the middle of his chest and it feels like a burning sensation along with tingling. Patient rated his pain 5 out of 10. Patient also stated that mostly happen when I am doing activity like climbing stairs however sometime it does happen when I am just watching TV. Patient denies any episodes of felling dizzy or passing out. Patient denied radiation of the pain to neck or jaw. He took Advil and it is not doing anything. Patient is non-compliance with his cholesterol medication.
ROS: General: has slowly gain weight over last ten years, denies weakness, , fevers, memory changes, nervousness, anxiety,depression, suicide.
Skin: no rash, lumps, sores, itching, dryness, color change, change in hair/nails, bruising or bleeding, excessive sweating, heat or cold intolerance.
Head: Denies headache, head injury, dizziness.
Eyes: no vision change, corrective lenses, pain redness, excessive tearing, double vision, blurred
vision, or blindness.
Ears: no hearing change, tinnitus, infection, discharge.
Nose/Sinus: negative for Rhinohea, No sinus pain or epistaxis.
Throat: No bleeding gums, dentures, sore tongue,dry mouth. Last dental exam 4 months ago.
Neck: No lumps, swollen glands, goiter, pain, or neck stiffness.
Neuro: No syncope, seizures, weakness, paralysis, numbness, tremors, or involuntary
movements.
Pulmonary: Dyspnea with activity, negative hemoptysis, wheezing, pleuritic pain
Neuro: No headache dizziness, focal numbness/weakness, nausea, vomiting.
Peripheral vascular: no claudication, leg cramps, varicose veins, history of blood clots,
abdominal, flank, or back pain. Pain in arms or legs. Intermittent claudication, cold, numbness,
pallor legs. Swelling in calves, legs, or feet. No color change in fingertips or toes in cold weather.
Swelling with redness or tenderness.
MS: no muscle, joint pain, or joint stiffness, positive for chest pain
GI: No changes in appetite, excessive hunger or thirst, jaundice, N/V, dysphagia, heartburn, pain,
belching/flatulence, change in bowel habits, hematochezia, melena, constipation, diarrhea, food
intolerance, indigestion, nausea, vomiting, early fullness, odynophagia.
GU: No suprapubic pain, dysuria, urgency, frequency, hesitancy, decreased stream, polyuria,
nocturia, incontinence, hematuria, kidney, or flank pain, ureteral colic, hemorrhoids.
Past Medical History: Hypertension, dyslipidemia
Surgeries: none
Hospitalizations: None
Allergies:.
Breast Cancer SOAP noteName Sharon BroomDate JanuarCicelyBourqueju
Breast Cancer SOAP note
Name Sharon Broom
Date: January/17/2020.
Age: 45 years old
Gender: Female
Time:12:45
SUBJECTIVE:
Chief Complaint:
“I have a sore lump on the left breast."
History of Present Illness:
Sharon is a 45-year-old female with complaints of a painful lump on her left breast for a month. The patient indicates that she feels unbalanced lumps on her left breast that are painful on the outer and upper corners. The patient observed the areas of the left outer breast worsening in terms of size and pain in the past week. She has experienced the pain of level four out of ten. Her mother was detected to have breast cancer prior to the age of 50. She has had a history of hysterectomy because of irregular periods, menorrhagia. The patient refutes swelling, increased warmth, and redness of the left breast. She repudiates nipple discharge swollen glands, chills, and fever.
History
Past Medical History:
Fibrocystic breast disease, Vitamin D deficiency, Urinary tract infection, Hypothyroidism, Hypocalcemia, and Constipation
Screenings:
Blood Pressure screening (2016 N/A)
Dental Examination (2016 N/A)
Eye Examination (2016 N/A)
Mammogram (2016 BiRad 2)
Pap smear- normal
HPV test- normal
GTPAL: G=1.T=0. P=0. A=0. L=1 (Normal vaginal delivery without complication)
Menstrual Hx: started at the age of 14. Normal PAP outcomes. LMP (cannot recall)-hysterectomy (07.2012)
Post Hospitalizations: Admitted to hospital for hysterectomy for one week
Past Surgical History: Hysterectomy (07. 2012)
Medications:
Armour Thyroid 30mg oral tablet: consume two pills on Monday, Wednesday, and Friday and three pills other days.
Therapy: 15 May 2015
Last Rx: 5 April 2016
Allergies:
Food allergies, Penicillin Triple Sulfa Vaginal CREA
Family History:
The patient’s mother passed away at the age of fifty, with a medical history of breast cancer. Sharon’s father is still alive at the age of seventy, with a medical record of hypertension. The patient has a younger brother aged 35 years and has no medical glitches. The patient has a sixteen-year-old son, who is healthy.
Social History:
The patient is divorced, and she lives with her son. She does not smoke but consumes alcohol irregularly. Sharon takes a regular diet that has no restrictions. She has no worries about weight loss or gains since she exercises two to three times weekly. The patient continually puts on a seatbelt when driving, wears sunscreen.
Sexual/Contraceptive History:
She has not been sexually active for at least a year, but previously, she had a monogamous relation. Birth control: Utilized condoms before. The patient has no fears with sexual performance or feelings.
...
Clinical Lecture Demonstration - Stroke and AF
Summary
74 years old known patient with hyperthyroidism, DM, HTN, DL, Paroxysmal AF & Thyrotoxic cardiomyopathy Presenting with right sided arm, leg weakness for two hours duration. No loss of consciousness preceding headaches fits or double vision. patient is a passive smoker. No other risk factors present. HTN is well controlled. On Examination Right sided UMN type Facial nerve palsy with dysarthria and Power, Tone, Reflexes are diminished on Right Upper and Lower limbs
by,
Pamudith Karunaratne
Heshani Karunanayake
Monali Kalupahana
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.
Social Skills Checklist (Elementary) - 1 - SOCIAL SKILLS CHECKLIST (E.docxhenry34567896
Social Skills Checklist (Elementary) - 1 -
SOCIAL SKILLS CHECKLIST (Elementary/Pre-K)
Name of child: ______________________ Date: _______________________ Birth date: __________________________ Assessor’s name: _______________ Instructions: For each question, check if that particular social skill occurs Almost Always, Often, Sometimes, or Almost Never.
RATING SCALE Almost always- the student consistently displays this skill in many settings and with a variety of people
Often- the student displays this skill on a few occasions, settings and with a few people
Sometimes- the student seldom displays this skill but may demonstrate it on infrequent occasions.
Almost Never- the student never or rarely exhibits this skill. It is uncommon to see this in their daily routine.
SOCIAL PLAY & EMOTIONAL DEVELOPMENT Almost Always Often Sometimes Almost
Never 1.1 Beginning Play Behaviors
1. Maintains proximity to peer within 1 foot
2. Observes peers in play vicinity within 3 feet
3. Parallel play near peers using the same or similar materials (e.g., playing cars near a peer who is also playing cars)
4. Physically imitates peer 5. Verbally imitates peer 6. Takes turns appropriately during simple games
1.2 Intermediate Play Behaviors 1. Shares toys and talks about the activity with peers, even
though the play agenda of the other children is different
2. Physically and verbally responds to interactions from peers (accepts toy from peer, answers questions)
3. Returns and initiates greetings with peers 4. Know appropriate ways of joining in an activity with peers 5. Invites others to play 6. Takes turns during structured activities 7. Obeys game rules 8. Requests toys, food, and materials from peers
1.3 Advanced Play Behavior 1. Plays cooperatively with peers during imaginative play 2. Makes comments about what he/she is playing to peers 3. Organizes play (suggests ideas to peers on how to play) 4. Follows peer play plans 5. Takes turns during unstructured activities without a time
limit
6. Offers toys, food, and materials to peers
Social Skills Checklist (Elementary) - 2 -
EMOTIONAL REGULATION Almost Always Often Sometimes Almost
Never 2.1 Understanding Emotions
1. Identifies likes and dislikes 2. Identifies emotions in self 3. Identifies emotions on others 4. Justifies emotions once identified (eating because I’m
hungry)
5. Demonstrates affection and empathy toward peers 6. Refrains from aggressive behaviors toward peers 7. Refrains from aggressive behaviors toward self 8. Does not exhibit intense fears or phobias 9. Interprets body language 10. Uses different tones of voice to convey messages
2.2 Self Regulation 1. Allows others to comfort him/her if upset or agitated 2. Self regulates when tense or upset 3. Self regulates when energy level is high 4. Deals with being teased in acceptable ways 5. Deals with being left out of a group 6. Accepts not being first at a game or activity 7. Accepts losing at a game without becoming upset/angry 8. Says “no†in a.
Social welfare programs are often associated with the federal governme.docxhenry34567896
Social welfare programs are often associated with the federal government, but they also illustrate the importance of state power in our system. Why do federally funded social welfare programs vary from state to state? Use one program (either means-tested or non-means tested) as an example. Use two paragraphs.
.
More Related Content
Similar to Soap notes will be uploaded to Moodle and put through TURN-It-In (anti.docx
(Student Name)Miami Regional UniversityDate of EncounterP.docxgertrudebellgrove
(Student Name)
Miami Regional University
Date of Encounter:
Preceptor/Clinical Site:
Clinical Instructor:
Soap Note # Main Diagnosis Diabetes Mellitus type 2
PATIENT INFORMATION
Name: Mr. ET
Age: 56-year-old
Gender at Birth: Female
Gender Identity: Female
Source: Patient
Allergies: Penicillins
Current Medications:
· Multi-Vitamin Centrum Silver
· Lisinopril 10 mg daily
· PMH: HTN
Diabetes mellitus type 2
Immunizations:
Preventive Care: Coloscopy 3 years ago (Negative)
Surgical History: laparoscopic cholecystectomy
Family History: Father alive
Mother-alive, 90 years old, Diabetes Mellitus, HTN
Daughter-alive, 21 years old, healthy
Social History: No smoking history or illicit drug use, occasional alcoholic beverage consumption on social celebrations. Retired, widow, she lives alone.
Sexual Orientation: Straight
Nutrition History: Diets off and on
Subjective Data:
Chief Complaint: “I cannot stop to drink water and to pee, I need to see my labs”
Symptom analysis/HPI:
The patient is 56 years old female who complaining of she cannot stop to drink water and to pee. Patient noticed the problem started 1 month ago and sometimes it is accompanied by anxious for eat. She states that she has been under stress because her daughter for the last month. Patient denies pain, or another symptom. She makes some labs and coming to see the results.
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 and Lab valuesTemperature: 97.5 °F, Pulse: 84, BP: 142/82 mmhg, RR 20, PO2-98% on room air, Ht- fill, Wt fill lb, BMI 37.2. No report pain 0/10.
HbA1C 9.5 %.
Serum creatinine 1.2 mg/dl, add more
GENERAL APPREARANCE: 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.
HE.
(Student Name)Miami Regional UniversityDate of EncounterP.docxgertrudebellgrove
(Student Name)
Miami Regional University
Date of Encounter:
Preceptor/Clinical Site:
Clinical Instructor:
Soap Note # Main Diagnosis Diabetes Mellitus type 2
PATIENT INFORMATION
Name: Mr. ET
Age: 56-year-old
Gender at Birth: Female
Gender Identity: Female
Source: Patient
Allergies: Penicillins
Current Medications:
· Multi-Vitamin Centrum Silver
· Lisinopril 10 mg daily
· PMH: HTN
Diabetes mellitus type 2
Immunizations:
Preventive Care: Coloscopy 3 years ago (Negative)
Surgical History: laparoscopic cholecystectomy
Family History: Father alive
Mother-alive, 90 years old, Diabetes Mellitus, HTN
Daughter-alive, 21 years old, healthy
Social History: No smoking history or illicit drug use, occasional alcoholic beverage consumption on social celebrations. Retired, widow, she lives alone.
Sexual Orientation: Straight
Nutrition History: Diets off and on
Subjective Data:
Chief Complaint: “I cannot stop to drink water and to pee, I need to see my labs”
Symptom analysis/HPI:
The patient is 56 years old female who complaining of she cannot stop to drink water and to pee. Patient noticed the problem started 1 month ago and sometimes it is accompanied by anxious for eat. She states that she has been under stress because her daughter for the last month. Patient denies pain, or another symptom. She makes some labs and coming to see the results.
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 and Lab valuesTemperature: 97.5 °F, Pulse: 84, BP: 142/82 mmhg, RR 20, PO2-98% on room air, Ht- fill, Wt fill lb, BMI 37.2. No report pain 0/10.
HbA1C 9.5 %.
Serum creatinine 1.2 mg/dl, add more
GENERAL APPREARANCE: 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.
HE ...
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
.
PATIENT INFORMATIONName Mr. W.S.Age 65-year-oldSex Male.docxJUST36
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 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 membrane.
Clinical Documentation Template
Subjective
Chief Complaint: 52 year old male present for three month follow and labs check.
HPI: A 52-year old male with PMH of Hyperlipidemia diabetes presents to the clinic for three month follow up. Patient complained of polyuria, polydipsia and polyphasia. Patient is presently taking plavix and sexagliptin. Patient denies any chest pain, fever and chills.
ROS
General: lost 15lbs in last one month, admit weakness, fatigue. Denies depression, suicide throught.
Skin: no rashes, no open wound..
Head: Denies headache, head injury, dizziness.
Eyes: no vision change, corrective lenses, pain redness, excessive tearing, double vision, blurred
vision, or blindness.
Ears: no hearing change, tinnitus, infection, discharge.
Nose/Sinus: negative for Rhinohea, No sinus pain or epistaxis.
Throat: No bleeding gums, dentures, sore tongue,dry mouth. Last dental exam 4 months ago.
Neck: No lumps, swollen glands, goiter, pain, or neck stiffness.
Neuro: experience syncope once a week, denies seizures, weakness, paralysis, numbness/tingling, tremors, or involuntary movements.
Pulmonary: negative hemoptysis, dyspnea, wheezing,pleuritic pain
Peripheral vascular: no claudication, leg cramps, varicose veins, history of blood clots,
abdominal, flank, or back pain. Pain in arms or legs. Intermittent claudication, cold, numbness,
pallor legs. Swelling in calves, legs, or feet. No color change in fingertips or toes in cold weather.
Swelling with redness or tenderness.
MS: no muscle, joint pain, or joint stiffness.
GI: No changes in appetite, excessive hunger or thirst, jaundice, N/V, dysphagia, heartburn, pain,
belching/flatulence, change in bowel habits, hematochezia, melena, constipation, diarrhea, food
intolerance, indigestion, nausea, vomiting, early fullness, odynophagia.
GU: No suprapubic pain, dysuria, urgency, frequency, hesitancy, decreased stream, polyuria,
nocturia, incontinence, hematuria, kidney, or flank pain, ureteral colic, hemorrhoids.
O:
Past Medical History: Hyperlipidemia, diabetes
Surgeries: Appendectomy, 2000
Hospitalizations: 2000 (for appendectomy)
Allergies: NKDA
Food, drug, environmental: None
Medications: Plavix 75 mg daily (prescribed by his PCP in INDIA as a prophylaxis to prevent Heart attack. We use Aspirin 81 mg here in USA)
Sexagliptin 5 mg daily
Family History: Gout (Father)
Diabetes (Mother)
.
Social History: Denies tobacco/e-cigarette and alcohol use.
Objective
Vital Signs: Temp 98.2 BP 128/90 Pulse 64 RR 18 Pain 0 Height 5’ 8” Weight 140 lb BMI 21.3 SpO2 97% @ RA
Labs: Lipid Panel
Cholesterol 272 mg/dl
Triglyceride 175 mg/dl
HDL 28 mg/dl
LDL 135 mg/dl
HgA1c 9.8%
Physical Exam:
HEENT:
Head: hair normal texture and distribution, no lumps/bumps/lesions noted to scalp. Scalp/skull non-tender with palpation. Skull normocephalic/atraumati.
SOAP NOTE SAMPLE FORMAT FOR MRCName LPDateTime 1315.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 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.
Clinical Documentation Template
Student: Deepak Sharma Site: Elgin Medical Ctr
Client’s Initials: MS Age : 64 Gender : Male Date: 04/07/2019
Subjective
Chief Complaint: 64 year old Hispanic male present to the clinic with chest discomfort.
HPI: Mr. JG. is a 64-year old male with a history of HTN and dyslipidemia present to the clinic with chest discomfort for past two month. Patient stated that chest discomfort is in the middle of his chest and it feels like a burning sensation along with tingling. Patient rated his pain 5 out of 10. Patient also stated that mostly happen when I am doing activity like climbing stairs however sometime it does happen when I am just watching TV. Patient denies any episodes of felling dizzy or passing out. Patient denied radiation of the pain to neck or jaw. He took Advil and it is not doing anything. Patient is non-compliance with his cholesterol medication.
ROS: General: has slowly gain weight over last ten years, denies weakness, , fevers, memory changes, nervousness, anxiety,depression, suicide.
Skin: no rash, lumps, sores, itching, dryness, color change, change in hair/nails, bruising or bleeding, excessive sweating, heat or cold intolerance.
Head: Denies headache, head injury, dizziness.
Eyes: no vision change, corrective lenses, pain redness, excessive tearing, double vision, blurred
vision, or blindness.
Ears: no hearing change, tinnitus, infection, discharge.
Nose/Sinus: negative for Rhinohea, No sinus pain or epistaxis.
Throat: No bleeding gums, dentures, sore tongue,dry mouth. Last dental exam 4 months ago.
Neck: No lumps, swollen glands, goiter, pain, or neck stiffness.
Neuro: No syncope, seizures, weakness, paralysis, numbness, tremors, or involuntary
movements.
Pulmonary: Dyspnea with activity, negative hemoptysis, wheezing, pleuritic pain
Neuro: No headache dizziness, focal numbness/weakness, nausea, vomiting.
Peripheral vascular: no claudication, leg cramps, varicose veins, history of blood clots,
abdominal, flank, or back pain. Pain in arms or legs. Intermittent claudication, cold, numbness,
pallor legs. Swelling in calves, legs, or feet. No color change in fingertips or toes in cold weather.
Swelling with redness or tenderness.
MS: no muscle, joint pain, or joint stiffness, positive for chest pain
GI: No changes in appetite, excessive hunger or thirst, jaundice, N/V, dysphagia, heartburn, pain,
belching/flatulence, change in bowel habits, hematochezia, melena, constipation, diarrhea, food
intolerance, indigestion, nausea, vomiting, early fullness, odynophagia.
GU: No suprapubic pain, dysuria, urgency, frequency, hesitancy, decreased stream, polyuria,
nocturia, incontinence, hematuria, kidney, or flank pain, ureteral colic, hemorrhoids.
Past Medical History: Hypertension, dyslipidemia
Surgeries: none
Hospitalizations: None
Allergies:.
Breast Cancer SOAP noteName Sharon BroomDate JanuarCicelyBourqueju
Breast Cancer SOAP note
Name Sharon Broom
Date: January/17/2020.
Age: 45 years old
Gender: Female
Time:12:45
SUBJECTIVE:
Chief Complaint:
“I have a sore lump on the left breast."
History of Present Illness:
Sharon is a 45-year-old female with complaints of a painful lump on her left breast for a month. The patient indicates that she feels unbalanced lumps on her left breast that are painful on the outer and upper corners. The patient observed the areas of the left outer breast worsening in terms of size and pain in the past week. She has experienced the pain of level four out of ten. Her mother was detected to have breast cancer prior to the age of 50. She has had a history of hysterectomy because of irregular periods, menorrhagia. The patient refutes swelling, increased warmth, and redness of the left breast. She repudiates nipple discharge swollen glands, chills, and fever.
History
Past Medical History:
Fibrocystic breast disease, Vitamin D deficiency, Urinary tract infection, Hypothyroidism, Hypocalcemia, and Constipation
Screenings:
Blood Pressure screening (2016 N/A)
Dental Examination (2016 N/A)
Eye Examination (2016 N/A)
Mammogram (2016 BiRad 2)
Pap smear- normal
HPV test- normal
GTPAL: G=1.T=0. P=0. A=0. L=1 (Normal vaginal delivery without complication)
Menstrual Hx: started at the age of 14. Normal PAP outcomes. LMP (cannot recall)-hysterectomy (07.2012)
Post Hospitalizations: Admitted to hospital for hysterectomy for one week
Past Surgical History: Hysterectomy (07. 2012)
Medications:
Armour Thyroid 30mg oral tablet: consume two pills on Monday, Wednesday, and Friday and three pills other days.
Therapy: 15 May 2015
Last Rx: 5 April 2016
Allergies:
Food allergies, Penicillin Triple Sulfa Vaginal CREA
Family History:
The patient’s mother passed away at the age of fifty, with a medical history of breast cancer. Sharon’s father is still alive at the age of seventy, with a medical record of hypertension. The patient has a younger brother aged 35 years and has no medical glitches. The patient has a sixteen-year-old son, who is healthy.
Social History:
The patient is divorced, and she lives with her son. She does not smoke but consumes alcohol irregularly. Sharon takes a regular diet that has no restrictions. She has no worries about weight loss or gains since she exercises two to three times weekly. The patient continually puts on a seatbelt when driving, wears sunscreen.
Sexual/Contraceptive History:
She has not been sexually active for at least a year, but previously, she had a monogamous relation. Birth control: Utilized condoms before. The patient has no fears with sexual performance or feelings.
...
Clinical Lecture Demonstration - Stroke and AF
Summary
74 years old known patient with hyperthyroidism, DM, HTN, DL, Paroxysmal AF & Thyrotoxic cardiomyopathy Presenting with right sided arm, leg weakness for two hours duration. No loss of consciousness preceding headaches fits or double vision. patient is a passive smoker. No other risk factors present. HTN is well controlled. On Examination Right sided UMN type Facial nerve palsy with dysarthria and Power, Tone, Reflexes are diminished on Right Upper and Lower limbs
by,
Pamudith Karunaratne
Heshani Karunanayake
Monali Kalupahana
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.
Social Skills Checklist (Elementary) - 1 - SOCIAL SKILLS CHECKLIST (E.docxhenry34567896
Social Skills Checklist (Elementary) - 1 -
SOCIAL SKILLS CHECKLIST (Elementary/Pre-K)
Name of child: ______________________ Date: _______________________ Birth date: __________________________ Assessor’s name: _______________ Instructions: For each question, check if that particular social skill occurs Almost Always, Often, Sometimes, or Almost Never.
RATING SCALE Almost always- the student consistently displays this skill in many settings and with a variety of people
Often- the student displays this skill on a few occasions, settings and with a few people
Sometimes- the student seldom displays this skill but may demonstrate it on infrequent occasions.
Almost Never- the student never or rarely exhibits this skill. It is uncommon to see this in their daily routine.
SOCIAL PLAY & EMOTIONAL DEVELOPMENT Almost Always Often Sometimes Almost
Never 1.1 Beginning Play Behaviors
1. Maintains proximity to peer within 1 foot
2. Observes peers in play vicinity within 3 feet
3. Parallel play near peers using the same or similar materials (e.g., playing cars near a peer who is also playing cars)
4. Physically imitates peer 5. Verbally imitates peer 6. Takes turns appropriately during simple games
1.2 Intermediate Play Behaviors 1. Shares toys and talks about the activity with peers, even
though the play agenda of the other children is different
2. Physically and verbally responds to interactions from peers (accepts toy from peer, answers questions)
3. Returns and initiates greetings with peers 4. Know appropriate ways of joining in an activity with peers 5. Invites others to play 6. Takes turns during structured activities 7. Obeys game rules 8. Requests toys, food, and materials from peers
1.3 Advanced Play Behavior 1. Plays cooperatively with peers during imaginative play 2. Makes comments about what he/she is playing to peers 3. Organizes play (suggests ideas to peers on how to play) 4. Follows peer play plans 5. Takes turns during unstructured activities without a time
limit
6. Offers toys, food, and materials to peers
Social Skills Checklist (Elementary) - 2 -
EMOTIONAL REGULATION Almost Always Often Sometimes Almost
Never 2.1 Understanding Emotions
1. Identifies likes and dislikes 2. Identifies emotions in self 3. Identifies emotions on others 4. Justifies emotions once identified (eating because I’m
hungry)
5. Demonstrates affection and empathy toward peers 6. Refrains from aggressive behaviors toward peers 7. Refrains from aggressive behaviors toward self 8. Does not exhibit intense fears or phobias 9. Interprets body language 10. Uses different tones of voice to convey messages
2.2 Self Regulation 1. Allows others to comfort him/her if upset or agitated 2. Self regulates when tense or upset 3. Self regulates when energy level is high 4. Deals with being teased in acceptable ways 5. Deals with being left out of a group 6. Accepts not being first at a game or activity 7. Accepts losing at a game without becoming upset/angry 8. Says “no†in a.
Social welfare programs are often associated with the federal governme.docxhenry34567896
Social welfare programs are often associated with the federal government, but they also illustrate the importance of state power in our system. Why do federally funded social welfare programs vary from state to state? Use one program (either means-tested or non-means tested) as an example. Use two paragraphs.
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Social cognition is about perceiving others and how we process the peo.docxhenry34567896
Social cognition is about perceiving others and how we process the people and the world around us.
How do people categorize things and people as either familiar and safe or unfamiliar and possibly dangerous?
Why do people categorize?
Can you escape categorization?
How does this impact us and how we navigate the world?
If we cannot escape categorization, can we ever eliminate prejudice?
Think about your current work situation—how there is certain work that is handled by individuals and work that is handled by teams.
When should we use groups to solve problems versus having an individual complete the work?
Discuss how your answer aligns with the theories and insights from the textbook.
.
Singer or ArthurCBC News- The Church service aid agency is warning tha.docxhenry34567896
Singer or Arthur
CBC News- The Church service aid agency is warning that†Immediate massive intervention and assistance†are needed to prevent mass starvation in Kenya. A team from the humanitarian agency reported recently that many fields are barren and cracked, dried out by the drought that is threatening a third of the east African country’s population, or about 10 million people.
What was once among the most fertile land I  Africa can now only support a few struggling plants suitable only for grazing cattle. “ We don’t have any foodâ€. Farmer Lizy Bimba, a Kwale resident, said in Swahili. In one area, a local official reported that 85% of 5,600 people are facing starvation, the church world service team said. Other farmers have left the land to find what work they can.†We have been forced to do this so that we get money to buy food.†Musa Charo said in Swahili as he broke rocks to earn money to feed his 10 children. The government declared the food shortage a national disaster on Jan. 16, the UN is appealing for international help and aid agencies warn that the problem will only get worse.
A/ What would be the proper moral response of rich nations to this impeding tragedy? Do you favor peter Singer’s path in which affluent individuals would be obligated to give much of their wealth to feef the hungry? Or Arthur’s way, in which the rich would have a duty to give some aid but would also have obligations to themselves and to their family and friends? Explain
.
Sexual differentiation is a complex developmental process beginning wi.docxhenry34567896
Sexual differentiation is a complex developmental process beginning with genetic factors established at conception and continuing up to the final form of the body. Discuss situations in which the end result of sexual differentiation is inconsistent with the initial genetic pattern (i.e., transgender, intersex, and sexual identity issues). Address the following:
How is gender development influenced by sexual differentiation?
To what extent is the statement that “gender is socially constructed†true?
.
Select TWO of the primary sources from the passage- Comment on how eac.docxhenry34567896
Select TWO Â of the primary sources from the passage. Comment on how each offers useful insight on that particular culture and society and how this insight aligns with our course content. what do we learn from this? be specific in your response.
* Make sure you use what is found in the textbook do not include any outside sources. And also, it has to tow separate points explaining what you think.
.
Select TWO of the primary sources from the passage- Comment on how eac (1).docxhenry34567896
Select TWO of the primary sources from the passage. Comment on how each offers useful insight on that particular culture and society and how that insight aligns with our course content. What do we learn from this? Be specific in your response.
* Make sure you use what is found in the textbook do not include any outside sources. And also, it has to tow separate points explaining what you think.
.
Select TWO passages from this passage (-Cato the Elder-)- In the first.docxhenry34567896
Select TWO Â passages from this passage ("Cato the Elder"). In the first, comment on the ways that cato aimed to appear to be a "traditional" Roman. Why do you think he did this? In the second, comment on his response to culture change underway in Roman society. Do you belive that he was justified in his position? Why or why not/ How does this align with course content ?
* Make sure you use what is found in the textbook do not include any outside sources. And also, it has to tow separate points explaining what you think.
.
Select one of the following three articles as the topic- -Our Blind.docxhenry34567896
Select one of the following three articles as the topic:
"Our Blind Spot About Guns", Nicholas Kristof, p. 177
"Representation of Disney Princesses in the Media," Isabelle Gill, p. 759
"Outbreak of the Irrational, Sarah Dzubay," p. 825
please look at attached.
.
Select one of the following ethical-legal topics- AutonomyBeneficen.docxhenry34567896
Select one of the following ethical/legal topics:
Autonomy
Beneficence
Justice
Fidelity
Veracity
Involuntary hospitalization and due process of civil commitment
Informed assent/consent and capacity
Duty to warn
Restraints
HIPPA
Child and elder abuse reporting
Tort law
Negligence/malpractice
locate a total of four scholarly, professional, or legal resources related to this topic. One should address ethical considerations related to this topic for adults, one should be on ethical considerations related to this topic for children/adolescents, one should be on legal considerations related to this topic for adults, and one should be on legal considerations related to this topic for children/adolescents.
Briefly identify the topic you selected. Then, summarize the articles you selected, explaining the most salient ethical and legal issues related to the topic as they concern psychiatric-mental health practice for children/adolescents and for adults. Explain how this information could apply to your clinical practice, including specific implications for practice within your state. Attach the PDFs of your articles.
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Select ONE of the following fugal agents for your assignment-Aspergill.docxhenry34567896
Select ONE of the following fugal agents for your assignment.
Aspergillus, Tinea pedis, Candida albicans, Coccidioides, Pneumocystis jirovecii, Blastomyces, Cryptococcus neoformans, Histoplasma, Tinea corporis
Step 2
Research the chosen fungal agent to examine the anatomical structures and diseases associated with it.
Step 3
Using the template below answer the following questions:
Where the organism is normally found and how is it spread?
What are the virulence factors of the organism?
What are the symptoms and incubation period of the infection caused by the organism?
How would you diagnose an infection caused by the organism?
Describe how the organism infects different organs and how the immune system responds to infection.
What is the current treatment plan for the infections caused by the organism and the treatment success rate?
What populations are most at risk for infection?
What environments and sources are associated with the organism?
What are some public health implications of the infection caused by the agent?
What precautions can the public take to prevent infections?
Assignment File(s)
Unit 6 Fungus Template
[Word document]
.
See attachedLet me know what if you can put this together- it's from t.docxhenry34567896
See attached
Let me know what if you can put this together, it's from the book. I'll provide all info you need.
Case Study
: You are required to complete parts 2,3, and 4. Please be sure to attach
all Word and Excel Files with your work included. Be sure to cite any source materials used.
Reference pages attached from book: Accounting fundamentals for health care management by Steven A. Funkier, Thad D. Calabrese & David M. Ward
.
School board trustees are requesting public comment before they vote o.docxhenry34567896
School board trustees are requesting public comment before they vote on a vaccination policy for all children in a local school district. Should individual rights (e.g., parents’ rights to decide whether to vaccinate their children) be compromised to control the spread of communicable diseases for the good of society?
.
School board trustees are requesting public comment before they vote o (1).docxhenry34567896
School board trustees are requesting public comment before they vote on a vaccination policy for all children in a local school district. Should individual rights (e.g., parents’ rights to decide whether to vaccinate their children) be compromised to control the spread of communicable diseases for the good of society?
.
ScenarioWesley Enterprises is a long-term care facility- The organizat (1).docxhenry34567896
Scenario
Wesley Enterprises is a long-term care facility. The organization was recently cited for deficiencies including infectious disease planning and staffing deficiencies. The CEO has decided to hire a consulting firm to evaluate its current processes and make recommendations for improvement. Upon initial review, the consulting firm has determined that Wesley is utilizing operational processes that are not consistent with current industry practices. The consulting firm has deployed a team of operations management professionals to address the concerns. You are the leader of the team and your first task is to meet with the mid-level managers at Wesley.
Instructions
Compile a multimedia presentation using speaker notes and/or voice narration that includes:
An introduction of the team and a comprehensive description of the roles of each operations team member;
A discussion of the goals of the team relative to process improvement;
A comparison of operations management in healthcare versus other industries; and
A detailed analysis of the operational issues that are unique to health organizations.
.
ScenarioWesley Enterprises is a long-term care facility- The organizat.docxhenry34567896
Scenario
Wesley Enterprises is a long-term care facility. The organization was recently cited for deficiencies including infectious disease planning and staffing deficiencies. The CEO has decided to hire a consulting firm to evaluate its current processes and make recommendations for improvement. Upon initial review, the consulting firm has determined that Wesley is utilizing operational processes that are not consistent with current industry practices. The consulting firm has deployed a team of operations management professionals to address the concerns. You are the leader of the team and your first task is to meet with the mid-level managers at Wesley.
Instructions
Compile a multimedia presentation using speaker notes and/or voice narration that includes:
An introduction of the team and a comprehensive description of the roles of each operations team member;
A discussion of the goals of the team relative to process improvement;
A comparison of operations management in healthcare versus other industries; and
A detailed analysis of the operational issues that are unique to health organizations.
.
ScenarioPeak View Sound Sources is a public company based in Denver- C.docxhenry34567896
Scenario
Peak View Sound Sources is a public company based in Denver, Colorado and is focused on providing digital media and Web sites to music companies and musicians through the Mountain and West Coast regions. The company has a solid reputation and is starting to get some national and worldwide attention, with new prospective companies wanting to take advantage of the quality services they have seen on other existing Web sites.
Your company has been hired to assist Peak View Sound Sources (PVSS) to ascertain the security posture of the company's Information Systems resources and services. You are heading the team of auditors tasked to perform the audit and assessment.
You enter the company offices of PVSS and begin your analysis of the environment and situation.
Initial analysis has allowed you to determine that the company is made up of the following divisions:
Corporate Management and Support Staff:
This organization contains the executive management, human resources, and accounting teams. All company decisions are directed from the management team.
Information Technology:
This team manages the networks, servers, Web sites, and desktop environments for the company. The team has a perception of being difficult to work with, as they are slow to adopt new technology and slow to implement new offerings. The reality is that the team has resources and wants to uptake the newest and greatest technology, but they spend most of their time putting out fires and reacting to issues.
Media Content and Design:
This team is in charge of working with the record companies and musicians to create the Web Sites and implement the product offerings that are sold.
Sales and Marketing:
This team works with the musicians and record companies to offer and sell the services of PVSS.
There is a concern about the security of the infrastructure with respect to the ability to protect the copyrighted material that PVSS is given to host, because a single incident several years ago took place in which an entire new CD was released prematurely via the Internet. Although PVSS was not directly linked to the leak, there are suspicions surrounding PVSS.
Assignment Deliverables
As you continue your analysis, you see that the Information Technology (IT) department has developed several guidelines and procedures about how various systems should be considered and set up, but this is internal only to the IT department. Every time a new machine is set up and deployed, within a month, the configuration is changed.
Explain why you think the use of these guidelines and procedures is not sufficient and may not solve the problem. Consider how a company-wide policy program could help the situation.
As you begin to prepare your game plan to conduct an Information Security Audit, talk about why you think this current situation makes it difficult to identify the controls that need to be examined.
If you were performing this security audit, wit.
Review this weeks Learning Resources providing an overview of human be.docxhenry34567896
Review this week’s Learning Resources providing an overview of human behavior and the social environment.
Consider how HBSE connects with social work practice. Why is it important for social workers to understand how the social environment influences behavior?
.
RUBRICCompetency1-Design evidence-based advanced nursing care for achi.docxhenry34567896
RUBRIC
Competency 1: Design evidence-based advanced nursing care for achieving high-quality population outcomes.
Evaluate the current state of the quality of care and outcomes for a specific issue in a target population.
Justify why a developed policy will be vital in improving the quality of care and outcomes for a specific issue in a target population.
Competency 2: Evaluate the efficiency and effectiveness of interprofessional interventions in achieving desired population health outcomes.
Analyze the ways in which interprofessional aspects of a developed policy will support efficient and effective achievement of desired outcomes for the target population.
Competency 3: Analyze population health outcomes in terms of their implications for health policy advocacy.
Analyze how the current state of the quality of care and outcomes for a specific issue in a target population necessitates health policy development and advocacy.
Advocate for policy development in other care settings with regard to a specific issue in a target population.
Competency 4: Communicate effectively with diverse audiences, in an appropriate form and style, consistent with organizational, professional, and scholarly standards.
Communicate in a professional and persuasive manner, writing content clearly and logically with correct use of grammar, punctuation, and spelling.
Integrate relevant sources to support assertions, correctly formatting citations and referenc
.
Review the components of credibility outlined in Chapter 1 of your tex.docxhenry34567896
Review the components of credibility outlined in Chapter 1 of your textbook and then think of a public communication from the last three months where someone communicated to you. This could be someone from your work, an event speaker (virtual or otherwise), a politician giving a televised speech, the public promotion or announcement of a product, or other public communication.
Identify the communication and then explain whether or not the speaker established credibility in a way that you trusted and that motivated you to listen to what they had to say. On the other hand, explain if they failed to establish or even lost credibility as they spoke. Be sure to provide specifics on how they did one or the other. Do you think their credibility or lack of credibility was specific to you or would it also be true for most people receiving the communication? Explain.
I sent chapter 1
.
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
How to Create Map Views in the Odoo 17 ERPCeline George
The map views are useful for providing a geographical representation of data. They allow users to visualize and analyze the data in a more intuitive manner.
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.
Instructions for Submissions thorugh G- Classroom.pptxJheel Barad
This presentation provides a briefing on how to upload submissions and documents in Google Classroom. It was prepared as part of an orientation for new Sainik School in-service teacher trainees. As a training officer, my goal is to ensure that you are comfortable and proficient with this essential tool for managing assignments and fostering student engagement.
The Art Pastor's Guide to Sabbath | Steve ThomasonSteve Thomason
What is the purpose of the Sabbath Law in the Torah. It is interesting to compare how the context of the law shifts from Exodus to Deuteronomy. Who gets to rest, and why?
Ethnobotany and Ethnopharmacology:
Ethnobotany in herbal drug evaluation,
Impact of Ethnobotany in traditional medicine,
New development in herbals,
Bio-prospecting tools for drug discovery,
Role of Ethnopharmacology in drug evaluation,
Reverse Pharmacology.
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.
How to Make a Field invisible in Odoo 17Celine George
It is possible to hide or invisible some fields in odoo. Commonly using “invisible” attribute in the field definition to invisible the fields. This slide will show how to make a field invisible in odoo 17.
Soap notes will be uploaded to Moodle and put through TURN-It-In (anti.docx
1. 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
2. : “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.
3. 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.
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 reboundno
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
4. 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:
Ø Renal artery stenosis(ICD10 I70.1)
Ø Chronic kidney disease(ICD10 I12.9)
Ø 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
· Complete blood count
· Lipid profile
· Thyroid-stimulating hormone
· Urinalysis
· Electrocardiogram
Ø
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.
Ø
Non-Pharmacologic treatment
:
5. · 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
· 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).
6. Codina Leik, M. T. (2014). Family Nurse Practitioner Certification Intensive Review (2nd ed.).
ISBN 978-0-8261-3424-0