This Assignment will assess your ability to evaluate subjective .docx
•Download as DOCX, PDF•
0 likes•7 views
This Assignment will assess your ability to evaluate subjective and objective information in order to arrive at an appropriate diagnosis and treatment plan for the patient. Hypertension Case Study C.D is a 55-year-old African American male who presents to his primary care provider with a 2-day history of a headache and chest pressure. PMH Allergic Rhinitis Depression Hypothyroidism Family History Father died at age 49 from AMI: had HTN Mother has DM and HTN Brother died at age 20 from complications of CF Two younger sisters are A&W Social History The patient has been married for 25 years and lives with his wife and two children. The patient is an air traffic controller at the local airport. He has smoked a pack of cigarettes a day for the past 15 years. He drinks several beers every evening after work to relax. He does not pay particular attention to sodium, fat, or carbohydrates in the foods he eats. He admits to “salting almost everything he eats, sometimes even before tasting it.” He denies ever having dieted or exercised. Medications Zyrtec 10 mg daily Allergies Penicillin ROS States that his overall health has been fair to good during the past year. Weight has increased by approximately 30 pounds in the last 12 months. States he has been having some occasional chest pressure and headaches for the past 2 days. Shortness of breath at rest, headaches, nocturia, nosebleeds, and hemoptysis. Reports some shortness of breath with activity, especially when climbing stairs and that breathing difficulties are getting worse. Denies any nausea, vomiting, diarrhea, or blood in stool. Self treats for occasional right knee pain with OTC Ibuprofen. Denies any genitourinary symptoms. Vital Signs B/P 190/120, HR 73, RR 18, T. 98.8 F., Ht 6’1”, Wt 240 lbs. HEENT TMs intact and clear throughout No nasal drainage No exudates or erythema in oropharynx PERRLA Funduscopy reveals mild arteriolar narrowing without nicking, hemorrhages, exudates, or papilledema Neck Supple without masses or bruits Thyroid normal No lymphadenopathy Lungs Mild basilar crackles bilaterally No wheezes Heart RRR No murmurs or rubs Abdomen Soft and non-distended No masses, bruits, or organomegaly Normal bowel sounds Ext Moves all extremities well Neuro No sensory or motor abnormalities CN’s II-XII intact DTR’s = 2+ Muscle tone=5/5 throughout What you should do: Develop an evidence-based management plan. Include any pertinent diagnostics. Describe the patient education plan. Include cultural and lifespan considerations. Provide information on health promotion or health care maintenance needs. Describe the follow-up and referral for this patient. Prepare a 3–5-page paper (not including the title page or reference page). Your writing Assignment should: follow the conventions of Standard English (correct grammar, punctuation, etc.); be well ordered , logical , and unified , as well as original and insightful ; displ.
Report
Share
Report
Share
Recommended
Hypertension Case StudyC.D is a 55-year-old African American male
Hypertension Case Study
C.D is a 55-year-old African American male who presents to his primary care provider with a 2-day history of a headache and chest pressure.
PMH
Allergic RhinitisDepressionHypothyroidism
Family History
Father died at age 49 from AMI: had HTNMother has DM and HTNBrother died at age 20 from complications of CFTwo younger sisters are A&W
Social History
The patient has been married for 25 years and lives with his wife and two children. The patient is an air traffic controller at the local airport. He has smoked a pack of cigarettes a day for the past 15 years. He drinks several beers every evening after work to relax. He does not pay particular attention to sodium, fat, or carbohydrates in the foods he eats. He admits to “salting almost everything he eats, sometimes even before tasting it.” He denies ever having dieted or exercised.
Medications
Zyrtec 10 mg daily
Allergies
Penicillin
ROS
States that his overall health has been fair to good during the past year.Weight has increased by approximately 30 pounds in the last 12 months.States he has been having some occasional chest pressure and headaches for the past 2 days. Shortness of breath at rest, headaches, nocturia, nosebleeds, and hemoptysis.Reports some shortness of breath with activity, especially when climbing stairs and that breathing difficulties are getting worse.Denies any nausea, vomiting, diarrhea, or blood in stool.Self treats for occasional right knee pain with OTC Ibuprofen.Denies any genitourinary symptoms.
Vital Signs
B/P 190/120, HR 73, RR 18, T. 98.8 F., Ht 6’1”, Wt 240 lbs.
HEENT
TMs intact and clear throughoutNo nasal drainageNo exudates or erythema in oropharynxPERRLAFunduscopy reveals mild arteriolar narrowing without nicking, hemorrhages, exudates, or papilledema
Neck
Supple without masses or bruitsThyroid normalNo lymphadenopathy
Lungs
Mild basilar crackles bilaterallyNo wheezes
Heart
RRRNo murmurs or rubs
Abdomen
Soft and non-distendedNo masses, bruits, or organomegalyNormal bowel sounds
Ext
Moves all extremities well
Neuro
No sensory or motor abnormalitiesCN’s II-XII intactDTR’s = 2+Muscle tone=5/5 throughout
What you should do:
Develop an evidence-based management plan.Include any pertinent diagnostics.Describe the patient education plan.Include cultural and lifespan considerations.Provide information on health promotion or health care maintenance needs.Describe the follow-up and referral for this patient.Prepare a 3–5-page paper (not including the title page or reference page).
Assignment Requirements:
Before finalizing your work, you should:be sure to
read the Assignment description carefully
(as displayed above);
consult the Grading Rubric
to make sure you have included everything necessary; andutilize
spelling
and
grammar check
to minimize errors.Your writing Assignment should:follow the conventions of
Standard English
(correct grammar, punctuation, etc.);be
well ordered
,
logical
, and
unified
, as well as
original and insightfu ...
Assignment DetailsThis Assignment will assess your ability t.docx
Assignment Details
This Assignment will assess your ability to evaluate subjective and objective information in order to arrive at an appropriate diagnosis and treatment plan for the patient.
Hypertension Case Study
C.D is a 55-year-old African American male who presents to his primary care provider with a 2-day history of a headache and chest pressure.
PMH
Allergic Rhinitis
Depression
Hypothyroidism
Family History
Father died at age 49 from AMI: had HTN
Mother has DM and HTN
Brother died at age 20 from complications of CF
Two younger sisters are A&W
Social History
The patient has been married for 25 years and lives with his wife and two children. The patient is an air traffic controller at the local airport. He has smoked a pack of cigarettes a day for the past 15 years. He drinks several beers every evening after work to relax. He does not pay particular attention to sodium, fat, or carbohydrates in the foods he eats. He admits to “salting almost everything he eats, sometimes even before tasting it.” He denies ever having dieted or exercised.
Medications
Zyrtec 10 mg daily
Allergies
Penicillin
ROS
States that his overall health has been fair to good during the past year.
Weight has increased by approximately 30 pounds in the last 12 months.
States he has been having some occasional chest pressure and headaches for the past 2 days. Shortness of breath at rest, headaches, nocturia, nosebleeds, and hemoptysis.
Reports some shortness of breath with activity, especially when climbing stairs and that breathing difficulties are getting worse.
Denies any nausea, vomiting, diarrhea, or blood in stool.
Self treats for occasional right knee pain with OTC Ibuprofen.
Denies any genitourinary symptoms.
Vital Signs
B/P 190/120, HR 73, RR 18, T. 98.8 F., Ht 6’1”, Wt 240 lbs.
HEENT
TMs intact and clear throughout
No nasal drainage
No exudates or erythema in oropharynx
PERRLA
Funduscopy reveals mild arteriolar narrowing without nicking, hemorrhages, exudates, or papilledema
Neck
Supple without masses or bruits
Thyroid normal
No lymphadenopathy
Lungs
Mild basilar crackles bilaterally
No wheezes
Heart
RRR
No murmurs or rubs
Abdomen
Soft and non-distended
No masses, bruits, or organomegaly
Normal bowel sounds
Ext
Moves all extremities well
Neuro
No sensory or motor abnormalities
CN’s II-XII intact
DTR’s = 2+
Muscle tone=5/5 throughout
What you should do:
Develop an evidence-based management plan.
Include any pertinent diagnostics.
Describe the patient education plan.
Include cultural and lifespan considerations.
Provide information on health promotion or health care maintenance needs.
Describe the follow-up and referral for this patient.
Prepare a 3–5-page paper (not including the title page or reference page).
Assignment Requirements:
Before finalizing your work, you should:
be sure to
read the Assignment description carefully
(as displayed above);
consult the Grading Rubric
to make sure .
Soap note Reflux Disease.docx
This soap note summarizes the assessment and plan of care for a 65-year-old male patient presenting with new onset headaches over the past two weeks. On examination, the patient was found to have elevated blood pressure readings of 159/100, 158/98 and 160/100 mmHg. Based on his symptoms and blood pressure readings, the patient was diagnosed with essential (primary) hypertension. The treatment plan included starting hydrochlorothiazide 25 mg daily, as well as lifestyle modifications like diet, exercise and stress reduction. Follow up with his primary care provider in one week was arranged to monitor his blood pressure control and medication response.
PATIENT INFORMATIONName Mr. W.S.Age 65-year-oldSex Male.docx
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.
Case Study Ankylosing Spondylitis.docx
This case study involves a 65-year-old male presenting with headaches and high blood pressure readings over the past two weeks. On examination, his blood pressure was elevated at 159/92 mmHg. The assessment is essential (primary) hypertension, given his symptoms and blood pressure levels. The plan is to initiate pharmacological treatment with hydrochlorothiazide and provide lifestyle counseling. Follow up with his primary care provider in a week is recommended to monitor his blood pressure and medication management.
SOAP NOTE SAMPLE FORMAT FOR MRCName LPDateTime 1315.docx
SOAP NOTE SAMPLE FORMAT FOR MRC
Name: LP
Date:
Time: 1315
Age: 30
Sex: F
SUBJECTIVE
CC:
“I am having vaginal itching and pain in my lower abdomen.”
HPI:
Pt is a 30y/o AA female, who is a new patient that has recently moved to Miami. She seeks treatment today after unsuccessful self-treatment of vaginal itching, burning upon urination, and lower abdominal pain. She is concerned for the presence of a vaginal or bladder infection, or an STD. Pt denies fever. She reports the itching and burning with urination has been present for 3 weeks, and the abdominal pain has been intermittent since months ago. Pt has tried OTC products for the itching, including Monistat and Vagisil. She denies any other urinary symptoms, including urgency or frequency. She describes the abdominal pain as either sharp or dull. The pain level goes as high as 8 out of 10 at times. 200mg of PO Advil PRN reduces the pain to a 7/10. Pt denies any aggravating factors for the pain. Pt reports that she did start her menstrual cycle this morning, but denies any other discharge other that light bleeding beginning today. Pt denies douching or the use of any vaginal irritants. She reports that she is in a stable sexual relationship, and denies any new sexual partners in the last 90 days. She denies any recent or historic known exposure to STDs. She reports the use of condoms with every coital experience, as well as this being her only form of contraceptive. She reports normal monthly menstrual cycles that last 3-4 days. She reports dysmenorrhea, which she also takes Advil for. She reports her last PAP smear was in 7/2016, was normal, and reports never having an abnormal PAP smear result. Pt denies any hx of pregnancies. Other medical hx includes GERD. She reports that she has an Rx for Protonix, but she does not take it every day. Her family hx includes the presence of DM and HTN.
Current Medications:
Protonix 40mg PO Daily for GERD
MTV OTC PO Daily
Advil 200mg OTC PO PRN for pain
PMHx:
Allergies:
NKA & NKDA
Medication Intolerances:
Denies
Chronic Illnesses/Major traumas
GERD
Hospitalizations/Surgeries
Denies
Family History
Father- DM & HTN; Mother- HTN; Older sister- DM & HTN; Maternal and paternal grandparents without known medical issues; 1 brother and 3 other sisters without known medical issues; No children.
Social History
Lives alone. Currently in a stable sexual relationship with one man. Works for DEFACS. Reports occasional alcohol use, but denies tobacco or illicit drug use.
ROS
General
Denies weight change, fatigue, fever, night sweats
Cardiovascular
Denies chest pain and edema. Reports rare palpitations that are relieved by drinking water
Skin
Denies any wounds, rashes, bruising, bleeding or skin discolorations, any changes in lesions
Respiratory
Denies cough. Reports dyspnea that accompanies the rare palpitations and is also relieved by drinking water
Eyes
Denies corrective lenses, blurring, visual changes of an.
Sample Soap NoteSoap Note # Main Diagnosis ( Exp H&P Note .docx
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
.
Mr. Brown is a 65 year old African American male who presents to.docx
Mr. Brown is a 65 year old African American male who presents to the clinic for a physical exam. He has not seen a provider in over 10 years and is here at the insistence of his wife. Lately he has been experiencing more “heartburn after I eat” but “nothing that I can’t live with.” Mr. Brown reports taking over the counter Pepcid about 2-3 times a week with some relief. Other than the reflux type symptoms, he denies any other medical issues. He just needed to get a checkup.
Allergies: Strawberries, NKDA
Current medications: Pepcid OTC as needed
PMH: GERD,
PSH: Tonsillectomy, appendectomy
Social: Tobacco: 1 PPD, Alcohol: 2-3 drinks every 3-4 days, Denies illegal drug use. He works fulltime at Lowe’s, does report some heavy lifting. He is married with 2 grown sons and 5 grandchildren. In a monogamous relationship. He is active, coaching little league football.
Immunizations: unsure
Family: Father: died at 72 of MI, Mother: died at 60 of breast cancer
ROS:
Constitional:
HEENT: Denies any headache, nasal congestion, ear pain
Cardiovascular: Denies chest pain
Respiratory: Denies any SOB, DOE, orthnopenia
GI: Reports some burning pain at times, feels like heartburn.
GU: Denies any painful urination, urgency, hesitancy
Musculoskeletal: Reports some knee pain with bending, walking long distances. Denies any swelling or redness
Neurological: Denies
Psychiatric: Denies suidicial ideations, depression. Does report difficulty falling asleep
Endocrine: Reports he has lost about 10 pounds over the last few months.
Hematologic/ Lymphatic: Denies any bruising
OBJECTIVE:
Vital signs: Ht: 70, Wt: 265, BP 178/94, HR 92, Resp: 16, SaO2: 95%
Constitutional: Well developed, obese male
HEENT: Oropharynx pink, moist, no lesions or exudate. Tonsils 1+ bilaterally. Teeth in good repair, no cavities noted. Tongue smooth, pink, no lesions, protrudes in midline. Neck supple. No cervical lymphadenopathy or tenderness noted. Thyroid midline, small and firm without palpable masses
Cardiovascular: RRR, No murmurs or rubs noted. No peripheral edema noted
Respiratory: Faint expiratory wheezes noted bilaterally, cleared after coughing.
GI: Abdomen round, soft, with bowel sounds noted in all four quadrants. No organo-megaly noted.
GU: Deferred
Musceloskeletal: Crepatus noted bil knees, no warmth or redness noted.
Integrementary: Skin warm and dry, No rashes noted
Neuro: Follows commands without difficulty
Working with your group, utilize the above case study a, develop a Voice Over PowerPoint presentation for your patient covering the problems identified in the case study and content in Unit 3 of Edelman, Kudzama, & Mandle (2018). Include the following:
2-Health Education
3-Complementary and Alternative Strategies
.
Recommended
Hypertension Case StudyC.D is a 55-year-old African American male
Hypertension Case Study
C.D is a 55-year-old African American male who presents to his primary care provider with a 2-day history of a headache and chest pressure.
PMH
Allergic RhinitisDepressionHypothyroidism
Family History
Father died at age 49 from AMI: had HTNMother has DM and HTNBrother died at age 20 from complications of CFTwo younger sisters are A&W
Social History
The patient has been married for 25 years and lives with his wife and two children. The patient is an air traffic controller at the local airport. He has smoked a pack of cigarettes a day for the past 15 years. He drinks several beers every evening after work to relax. He does not pay particular attention to sodium, fat, or carbohydrates in the foods he eats. He admits to “salting almost everything he eats, sometimes even before tasting it.” He denies ever having dieted or exercised.
Medications
Zyrtec 10 mg daily
Allergies
Penicillin
ROS
States that his overall health has been fair to good during the past year.Weight has increased by approximately 30 pounds in the last 12 months.States he has been having some occasional chest pressure and headaches for the past 2 days. Shortness of breath at rest, headaches, nocturia, nosebleeds, and hemoptysis.Reports some shortness of breath with activity, especially when climbing stairs and that breathing difficulties are getting worse.Denies any nausea, vomiting, diarrhea, or blood in stool.Self treats for occasional right knee pain with OTC Ibuprofen.Denies any genitourinary symptoms.
Vital Signs
B/P 190/120, HR 73, RR 18, T. 98.8 F., Ht 6’1”, Wt 240 lbs.
HEENT
TMs intact and clear throughoutNo nasal drainageNo exudates or erythema in oropharynxPERRLAFunduscopy reveals mild arteriolar narrowing without nicking, hemorrhages, exudates, or papilledema
Neck
Supple without masses or bruitsThyroid normalNo lymphadenopathy
Lungs
Mild basilar crackles bilaterallyNo wheezes
Heart
RRRNo murmurs or rubs
Abdomen
Soft and non-distendedNo masses, bruits, or organomegalyNormal bowel sounds
Ext
Moves all extremities well
Neuro
No sensory or motor abnormalitiesCN’s II-XII intactDTR’s = 2+Muscle tone=5/5 throughout
What you should do:
Develop an evidence-based management plan.Include any pertinent diagnostics.Describe the patient education plan.Include cultural and lifespan considerations.Provide information on health promotion or health care maintenance needs.Describe the follow-up and referral for this patient.Prepare a 3–5-page paper (not including the title page or reference page).
Assignment Requirements:
Before finalizing your work, you should:be sure to
read the Assignment description carefully
(as displayed above);
consult the Grading Rubric
to make sure you have included everything necessary; andutilize
spelling
and
grammar check
to minimize errors.Your writing Assignment should:follow the conventions of
Standard English
(correct grammar, punctuation, etc.);be
well ordered
,
logical
, and
unified
, as well as
original and insightfu ...
Assignment DetailsThis Assignment will assess your ability t.docx
Assignment Details
This Assignment will assess your ability to evaluate subjective and objective information in order to arrive at an appropriate diagnosis and treatment plan for the patient.
Hypertension Case Study
C.D is a 55-year-old African American male who presents to his primary care provider with a 2-day history of a headache and chest pressure.
PMH
Allergic Rhinitis
Depression
Hypothyroidism
Family History
Father died at age 49 from AMI: had HTN
Mother has DM and HTN
Brother died at age 20 from complications of CF
Two younger sisters are A&W
Social History
The patient has been married for 25 years and lives with his wife and two children. The patient is an air traffic controller at the local airport. He has smoked a pack of cigarettes a day for the past 15 years. He drinks several beers every evening after work to relax. He does not pay particular attention to sodium, fat, or carbohydrates in the foods he eats. He admits to “salting almost everything he eats, sometimes even before tasting it.” He denies ever having dieted or exercised.
Medications
Zyrtec 10 mg daily
Allergies
Penicillin
ROS
States that his overall health has been fair to good during the past year.
Weight has increased by approximately 30 pounds in the last 12 months.
States he has been having some occasional chest pressure and headaches for the past 2 days. Shortness of breath at rest, headaches, nocturia, nosebleeds, and hemoptysis.
Reports some shortness of breath with activity, especially when climbing stairs and that breathing difficulties are getting worse.
Denies any nausea, vomiting, diarrhea, or blood in stool.
Self treats for occasional right knee pain with OTC Ibuprofen.
Denies any genitourinary symptoms.
Vital Signs
B/P 190/120, HR 73, RR 18, T. 98.8 F., Ht 6’1”, Wt 240 lbs.
HEENT
TMs intact and clear throughout
No nasal drainage
No exudates or erythema in oropharynx
PERRLA
Funduscopy reveals mild arteriolar narrowing without nicking, hemorrhages, exudates, or papilledema
Neck
Supple without masses or bruits
Thyroid normal
No lymphadenopathy
Lungs
Mild basilar crackles bilaterally
No wheezes
Heart
RRR
No murmurs or rubs
Abdomen
Soft and non-distended
No masses, bruits, or organomegaly
Normal bowel sounds
Ext
Moves all extremities well
Neuro
No sensory or motor abnormalities
CN’s II-XII intact
DTR’s = 2+
Muscle tone=5/5 throughout
What you should do:
Develop an evidence-based management plan.
Include any pertinent diagnostics.
Describe the patient education plan.
Include cultural and lifespan considerations.
Provide information on health promotion or health care maintenance needs.
Describe the follow-up and referral for this patient.
Prepare a 3–5-page paper (not including the title page or reference page).
Assignment Requirements:
Before finalizing your work, you should:
be sure to
read the Assignment description carefully
(as displayed above);
consult the Grading Rubric
to make sure .
Soap note Reflux Disease.docx
This soap note summarizes the assessment and plan of care for a 65-year-old male patient presenting with new onset headaches over the past two weeks. On examination, the patient was found to have elevated blood pressure readings of 159/100, 158/98 and 160/100 mmHg. Based on his symptoms and blood pressure readings, the patient was diagnosed with essential (primary) hypertension. The treatment plan included starting hydrochlorothiazide 25 mg daily, as well as lifestyle modifications like diet, exercise and stress reduction. Follow up with his primary care provider in one week was arranged to monitor his blood pressure control and medication response.
PATIENT INFORMATIONName Mr. W.S.Age 65-year-oldSex Male.docx
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.
Case Study Ankylosing Spondylitis.docx
This case study involves a 65-year-old male presenting with headaches and high blood pressure readings over the past two weeks. On examination, his blood pressure was elevated at 159/92 mmHg. The assessment is essential (primary) hypertension, given his symptoms and blood pressure levels. The plan is to initiate pharmacological treatment with hydrochlorothiazide and provide lifestyle counseling. Follow up with his primary care provider in a week is recommended to monitor his blood pressure and medication management.
SOAP NOTE SAMPLE FORMAT FOR MRCName LPDateTime 1315.docx
SOAP NOTE SAMPLE FORMAT FOR MRC
Name: LP
Date:
Time: 1315
Age: 30
Sex: F
SUBJECTIVE
CC:
“I am having vaginal itching and pain in my lower abdomen.”
HPI:
Pt is a 30y/o AA female, who is a new patient that has recently moved to Miami. She seeks treatment today after unsuccessful self-treatment of vaginal itching, burning upon urination, and lower abdominal pain. She is concerned for the presence of a vaginal or bladder infection, or an STD. Pt denies fever. She reports the itching and burning with urination has been present for 3 weeks, and the abdominal pain has been intermittent since months ago. Pt has tried OTC products for the itching, including Monistat and Vagisil. She denies any other urinary symptoms, including urgency or frequency. She describes the abdominal pain as either sharp or dull. The pain level goes as high as 8 out of 10 at times. 200mg of PO Advil PRN reduces the pain to a 7/10. Pt denies any aggravating factors for the pain. Pt reports that she did start her menstrual cycle this morning, but denies any other discharge other that light bleeding beginning today. Pt denies douching or the use of any vaginal irritants. She reports that she is in a stable sexual relationship, and denies any new sexual partners in the last 90 days. She denies any recent or historic known exposure to STDs. She reports the use of condoms with every coital experience, as well as this being her only form of contraceptive. She reports normal monthly menstrual cycles that last 3-4 days. She reports dysmenorrhea, which she also takes Advil for. She reports her last PAP smear was in 7/2016, was normal, and reports never having an abnormal PAP smear result. Pt denies any hx of pregnancies. Other medical hx includes GERD. She reports that she has an Rx for Protonix, but she does not take it every day. Her family hx includes the presence of DM and HTN.
Current Medications:
Protonix 40mg PO Daily for GERD
MTV OTC PO Daily
Advil 200mg OTC PO PRN for pain
PMHx:
Allergies:
NKA & NKDA
Medication Intolerances:
Denies
Chronic Illnesses/Major traumas
GERD
Hospitalizations/Surgeries
Denies
Family History
Father- DM & HTN; Mother- HTN; Older sister- DM & HTN; Maternal and paternal grandparents without known medical issues; 1 brother and 3 other sisters without known medical issues; No children.
Social History
Lives alone. Currently in a stable sexual relationship with one man. Works for DEFACS. Reports occasional alcohol use, but denies tobacco or illicit drug use.
ROS
General
Denies weight change, fatigue, fever, night sweats
Cardiovascular
Denies chest pain and edema. Reports rare palpitations that are relieved by drinking water
Skin
Denies any wounds, rashes, bruising, bleeding or skin discolorations, any changes in lesions
Respiratory
Denies cough. Reports dyspnea that accompanies the rare palpitations and is also relieved by drinking water
Eyes
Denies corrective lenses, blurring, visual changes of an.
Sample Soap NoteSoap Note # Main Diagnosis ( Exp H&P Note .docx
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
.
Mr. Brown is a 65 year old African American male who presents to.docx
Mr. Brown is a 65 year old African American male who presents to the clinic for a physical exam. He has not seen a provider in over 10 years and is here at the insistence of his wife. Lately he has been experiencing more “heartburn after I eat” but “nothing that I can’t live with.” Mr. Brown reports taking over the counter Pepcid about 2-3 times a week with some relief. Other than the reflux type symptoms, he denies any other medical issues. He just needed to get a checkup.
Allergies: Strawberries, NKDA
Current medications: Pepcid OTC as needed
PMH: GERD,
PSH: Tonsillectomy, appendectomy
Social: Tobacco: 1 PPD, Alcohol: 2-3 drinks every 3-4 days, Denies illegal drug use. He works fulltime at Lowe’s, does report some heavy lifting. He is married with 2 grown sons and 5 grandchildren. In a monogamous relationship. He is active, coaching little league football.
Immunizations: unsure
Family: Father: died at 72 of MI, Mother: died at 60 of breast cancer
ROS:
Constitional:
HEENT: Denies any headache, nasal congestion, ear pain
Cardiovascular: Denies chest pain
Respiratory: Denies any SOB, DOE, orthnopenia
GI: Reports some burning pain at times, feels like heartburn.
GU: Denies any painful urination, urgency, hesitancy
Musculoskeletal: Reports some knee pain with bending, walking long distances. Denies any swelling or redness
Neurological: Denies
Psychiatric: Denies suidicial ideations, depression. Does report difficulty falling asleep
Endocrine: Reports he has lost about 10 pounds over the last few months.
Hematologic/ Lymphatic: Denies any bruising
OBJECTIVE:
Vital signs: Ht: 70, Wt: 265, BP 178/94, HR 92, Resp: 16, SaO2: 95%
Constitutional: Well developed, obese male
HEENT: Oropharynx pink, moist, no lesions or exudate. Tonsils 1+ bilaterally. Teeth in good repair, no cavities noted. Tongue smooth, pink, no lesions, protrudes in midline. Neck supple. No cervical lymphadenopathy or tenderness noted. Thyroid midline, small and firm without palpable masses
Cardiovascular: RRR, No murmurs or rubs noted. No peripheral edema noted
Respiratory: Faint expiratory wheezes noted bilaterally, cleared after coughing.
GI: Abdomen round, soft, with bowel sounds noted in all four quadrants. No organo-megaly noted.
GU: Deferred
Musceloskeletal: Crepatus noted bil knees, no warmth or redness noted.
Integrementary: Skin warm and dry, No rashes noted
Neuro: Follows commands without difficulty
Working with your group, utilize the above case study a, develop a Voice Over PowerPoint presentation for your patient covering the problems identified in the case study and content in Unit 3 of Edelman, Kudzama, & Mandle (2018). Include the following:
2-Health Education
3-Complementary and Alternative Strategies
.
Mrs. Jones is a 32 year old Caucasian female who presents for fo.docx
A 32-year-old woman presents for follow-up for gestational diabetes. She was diagnosed with gestational diabetes during her first pregnancy 3 months ago but has not checked her blood glucose since leaving the hospital due to being busy. She has a strong family history of diabetes and was told to monitor her blood glucose after weaning from breastfeeding. On examination, she is overweight but otherwise healthy. She reports increased fatigue and difficulty sleeping.
62181184 quinx-case-study
Mrs. A, a 76-year-old woman with a history of hypertension and stroke, presented with body weakness. Her physical exam found weakness on her right side and enlarged heart on chest x-ray. Lab results showed abnormal cholesterol and electrolyte levels. She was diagnosed with uncontrolled hypertension and given medications to control her blood pressure along with dietary and lifestyle counseling upon discharge.
Soap notes will be uploaded to Moodle and put through TURN-It-In (an
Soap notes will be uploaded to Moodle and put through TURN-It-In (anti-Plagiarism program)
Turn it in Score must be less than 50% or will not be accepted for credit, must be your own work and in your own words. You can resubmit, Final submission will be accepted if less than 50%. Copy paste from websites or textbooks will not be accepted or tolerated. Please see College Handbook with reference to Academic Misconduct Statement.
Example:
PATIENT INFORMATION
Name: Mr. W.S.
Age: 65-year-old
Sex: Male
Source: Patient
Allergies: None
Current Medications: Atorvastatin tab 20 mg, 1-tab PO at bedtime
PMH: Hypercholesterolemia
Immunizations: Influenza last 2018-year, tetanus, and hepatitis A and B 4 years ago.
Surgical History: Appendectomy 47 years ago.
Family History: Father- died 81 does not report information
Mother-alive, 88 years old, Diabetes Mellitus, HTN
Daughter-alive, 34 years old, healthy
Social Hx: No smoking history or illicit drug use, occasional alcoholic beverage consumption on social celebrations. Retired, widow, he lives alone.
SUBJECTIVE:
Chief complain
: “headaches” that started two weeks ago
Symptom analysis/HPI:
The patient is 65 years old male who complaining of episodes of headaches and on 3 different occasions blood pressure was measured, which was high (159/100, 158/98 and 160/100 respectively). Patient noticed the problem started two weeks ago and sometimes it is accompanied by dizziness.He states that he has been under stress in his workplace for the last month.
Patient denies chest pain, palpitation, shortness of breath, nausea or vomiting.
ROS:
CONSTITUTIONAL
: Denies fever or chills. Denies weakness or weight loss.
NEUROLOGIC
: Headache and dizzeness as describe above. Denies changes in LOC. Denies history of tremors or seizures.
HEENT
: HEAD: Denies any head injury, or change in LOC. Eyes: Denies any changes in vision, diplopia or blurred vision. Ear: Denies pain in the ears. Denies loss of hearing or drainage. Nose: Denies nasal drainage, congestion. THROAT: Denies throat or neck pain, hoarseness, difficulty swallowing.
Respiratory
:Patient denies shortness of breath, cough or hemoptysis.
Cardiovascular
: No chest pain, tachycardia. No orthopnea or paroxysmal nocturnal
dyspnea.
Gastrointestinal
:Denies abdominal pain or discomfort.Denies flatulence, nausea, vomiting or
diarrhea.
Genitourinary
: Denies hematuria, dysuria or change in urinary frequency. Denies difficulty starting/stopping stream of urine or incontinence.
MUSCULOSKELETAL
: Denies falls or pain. Denies hearing a clicking or snapping sound.
Skin
: No change of coloration such as cyanosis or jaundice, no rashes or pruritus.
Objective Data
CONSTITUTIONAL
: Vital signs: Temperature: 98.5 °F, Pulse: 87, BP: 159/92 mmhg, RR 20, PO2-98% on room air, Ht- 6’4”, Wt 200 lb, BMI 25. Report pain 0/10.
General appearance: The patient is alert and oriented x 3. No acute distress noted.
NEUROLOGIC:
Alert, CNII-XII grossly intac ...
Soap Note Hypertension Draft.docx
1. This SOAP note is for a 65-year-old male patient who presented with headaches and high blood pressure readings over the past two weeks.
2. On examination, the patient's blood pressure was 159/92 mmHg. No other abnormalities were found.
3. The patient was diagnosed with essential (primary) hypertension. The treatment plan includes lifestyle modifications and starting hydrochlorothiazide 25 mg daily. Follow-up with his primary care provider in one week is recommended to monitor his blood pressure.
Soap Note # Main Diagnosis ( Exp H&P Note #3 DX Hypertension).docx
Soap Note # Main Diagnosis ( Exp: H&P Note #3 DX: Hypertension)
Student Name
Miami Regional University
Date of Encounter:
Preceptor/Clinical Site:
Clinical Instructor: Dr. Rafael Camejo
Soap Note #
Main Diagnosis
( Exp: Soap Note #3 DX: Hypertension)
PATIENT INFORMATION
Name
: Mr. DT
Age
: 68-year-old
Gender at Birth:
Male
Gender Identity
: Male
Source
: Patient
Allergies
: PCN, Iodine
Current Medications:
· Atorvastatin tab 20 mg, 1-tab PO at bedtime
· ASA 81mg po daily
· Multi-Vitamin Centrum Silver
PMH:
Hypercholesterolemia
Immunizations:
Influenza last 2018-year, tetanus, and hepatitis A and B 4 years ago.
Preventive Care
: Coloscopy 5 years ago (Negative)
Surgical History
: Appendectomy 47 years ago.
Family History
: Father- died 81 does not report information
Mother-alive, 88 years old, Diabetes Mellitus, HTN
Daughter-alive, 34 years old, healthy
Social History
: No smoking history or illicit drug use, occasional alcoholic beverage consumption on social celebrations. Retired, widow, he lives alone.
Sexual Orientation
: Straight
Nutrition History
: Diets off and on, Does not each seafood
Subjective Data:
Chief Complaint
: “headaches” that started two weeks ago
Symptom analysis/HPI:
The patient is 65 years old male who complaining of episodes of headaches and on 3 different occasions blood pressure was measured, which was high (159/100, 158/98 and 160/100 respectively). Patient noticed the problem started two weeks ago and sometimes it is accompanied by dizziness. He states that he has been under stress in his workplace for the last month. Patient denies chest pain, palpitation, shortness of breath, nausea or vomiting.
Review of Systems (ROS)
CONSTITUTIONAL
: Denies fever or chills. Denies weakness or weight loss.
NEUROLOGIC
: Headache and dizziness as describe above. Denies changes in LOC. Denies history of tremors or seizures.
HEENT
: HEAD: Denies any head injury, or change in LOC. Eyes: Denies any changes in vision, diplopia or blurred vision. Ear: Denies pain in the ears. Denies loss of hearing or drainage. Nose: Denies nasal drainage, congestion. THROAT: Denies throat or neck pain, hoarseness, difficulty swallowing.
RESPIRATORY
: Patient denies shortness of breath, cough or hemoptysis.
CARDIOVASCULAR
: No chest pain, tachycardia. No orthopnea or paroxysmal nocturnal
dyspnea.
GASTROINTESTINAL
: Denies abdominal pain or discomfort. Denies flatulence, nausea, vomiting or
diarrhea.
GENITOURINARY
: Denies hematuria, dysuria or change in urinary frequency. Denies difficulty starting/stopping stream of urine or incontinence.
MUSCULOSKELETAL
: Denies falls or pain. Denies hearing a clicking or snapping sound.
SKIN
: No change of coloration such as cyanosis or jaundice, no rashes or pruritus.
Objective Data:
VITAL SIGNS:
Temperature: 98.5 °F, Pulse: 87, BP: 159/92 mmhg, RR 20, PO2-98% on room air, Ht- 6’4”, Wt 200 lb, BMI 25. Report pain 2/10.
GENERAL APPREARANCE
: The patient is aler.
soap Duodenal Ulcer.docx
This soap note is for a 68-year-old male presenting with headaches and high blood pressure readings over the past two weeks. On examination, his blood pressure was elevated at 159/92 mmHg. The main diagnosis is essential (primary) hypertension. Differential diagnoses include renal artery stenosis, chronic kidney disease, and hyperthyroidism. The plan is to order labs and diagnostic tests, start antihypertensive medications, implement non-pharmacologic treatments like diet and exercise changes, and follow-up in one week to manage his blood pressure.
(Student Name) UniversityDate of EncounterPreceptorClini
(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 EncounterPreceptorClini
1. The patient is a 68-year-old male who presented with headaches and high blood pressure readings over the past two weeks. On examination, his blood pressure was elevated at 159/92 mmHg.
2. The main diagnosis is essential (primary) hypertension given the symptoms and elevated blood pressure readings with no identifiable cause found. Differential diagnoses considered include renal artery stenosis, chronic kidney disease, and hyperthyroidism.
3. Labs, diagnostic tests, pharmacologic treatment with hydrochlorothiazide and lisinopril, and non-pharmacologic recommendations including lifestyle changes and follow up in 1 week are included in the treatment plan.
Soap notes will be uploaded to Moodle and put through TURN-It-In (anti.docx
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.docx
This soap note documents a visit for a 65-year-old male patient complaining of headaches for the past two weeks. On examination, the patient's blood pressure was elevated on multiple readings. The assessment is essential (primary) hypertension. The plan includes starting hydrochlorothiazide 25 mg daily, as well as lifestyle modifications and follow up with his primary care provider in one week to evaluate blood pressure control. No referrals are needed at this time.
Pulmonary Case PresentationsPlease select one case presentation be.docx
Pulmonary Case Presentations
Please select one case presentation below and provide answers to the following;
Three differential diagnoses
Definitive diagnosis
Management plan (include appropriate treatment/diagnostic tests)
Indications for referral and/or consultations (if needed)
Health education/lifespan considerations
Schedule a F/U appointment
Case I:
50 Y/O CM present with C/O dry cough x 4-5 months with 20 year H/O tobacco use of 1PPD for 20 years. Cough has become progressively worse over the past 2-3 weeks with yellow sputum production. Took OTC cough syrup without relief of symptoms. Afebrile at home. No CP or fatigue except with excessive coughing. No HAs or head injuries. No eye pain or drainage. No ear pain or difficulty hearing. Ocass. nasal drainage of clear mucus. No sore throat or difficulty swallowing. No neck pain or stiffness. Some SOB with excessive coughing. Excessive coughing interferes with ability to perform ADLs at times. No other household members with similar symptoms.
Temp--97.2
Pulse--94
B/P 140/90
RR- 24
Pulse Ox check-- 86% on Room Air
General: Alert, apprehensive but cooperative
SKIN: W/D with rapid recoil
HEENT: Normocephalic. PERRL, sclera clear, Bil. TMs pearly gray. Boggy, pale nasal mucosa. Oropharynx without erythema or exudate
NECK: Supple without LAD (lymphadenopathy)
HEART: Tachycardia without murmur, gallops or clicks
RESP: Distant lung sounds; positive rales at base with expiratory wheezes
Case II: (mom is present and is historian)
3 Y/O Asian male present with 3 day H/O dry cough that’s worse when playing outside near Spring flowers. Took OTC cough suppressant with cough resolved but reoccurred. Afebrile at home. Positive sneezing and itchy eyes at times. Consumes fluid and solid foods without difficulty. Mom reports tiring easily when outside playing with other children in neighborhood. No SOB noted per mom. Remain active and playful. No change in urinary habits with last BM this a.m, of soft brown consistency.
Temp--98.4
Pulse--104
B/P 80/68
RR- 26
Pulse Ox check-- 95%
General: Alert, cooperative without distress.
SKIN: W/D with rapid recoil
HEENT: Normocephalic. PERRL, sclera clear, Bil.TMs pearly gray. Boggy, pale nasal mucosa. O/P without erythema, masses, or lesions. Pink, moist mucous membranes.
NECK: Supple without LAD
HEART: Regular rate and rhythm (RRR) without murmur
RESP: Expiratory wheezing without retractions or nasal flaring
ABD: Soft, round, NT with positive BS
Case III:
J. V., a 24-year-old man, is admitted to the emergency department after a motorcycle accident. He is having trouble in breathing and is very upset. The rescue personnel tell you that his breath sounds are absent on the right side, his chest expands unequally, and that there is tracheal shift toward the left. There is a large contusion on his right rib cage.
Temp--97.2
Pulse--110
B/P 140/92
RR- 28
Pulse Ox check-- 88%
General: Alert & apprehensive
SKIN: Cool & diaphoretic; bluish discoloration to right anterior thorax.
Hypertension
This document discusses hypertension including its definition, prevalence, causes, complications, evaluation, treatment goals, and lifestyle and pharmacological interventions. Some key points:
- Hypertension is defined as blood pressure over 140/90 mmHg and affects over 50 million Americans. It is a primary risk factor for heart disease and stroke.
- Accurate blood pressure measurement requires proper technique and equipment. Target organ damage from uncontrolled hypertension can affect the heart, brain, kidneys, and eyes.
- Evaluation involves assessing cardiovascular risk factors, identifying secondary causes, and checking for target organ damage. Treatment goals are blood pressure under 140/90 mmHg or 130/80 for those with diabetes or kidney disease.
- Lifestyle
HYPERTENSION (4).ppt
This document discusses hypertension including its prevalence, definition, accurate measurement, classification, secondary causes, target organ damage, evaluation, treatment goals, and lifestyle modifications. Some key points:
- Hypertension is very common, affecting over 50 million Americans. It increases risks of heart disease, stroke, and kidney disease.
- It is defined as a systolic blood pressure over 139 mmHg or diastolic over 89 mmHg based on multiple readings.
- Lifestyle changes like following the DASH diet, reducing sodium, weight loss, and exercise are effective non-pharmacological interventions. The treatment goal is a blood pressure under 140/90 mmHg or under 130/80 for those with diabetes or kidney disease.
4. Ischemic Heart Disease with Hypertension-Dr.Fatema.pptx
A 74-year-old man presented with abdominal pain, nausea, vomiting and fever for 2 days. He has a history of hypertension and ischemic heart disease treated with medications. On examination, he had tenderness in the right lower quadrant. Tests showed elevated white blood cell count and ultrasound revealed inflamed appendix with fluid in the right lower quadrant. The provisional diagnosis was acute appendicitis requiring an emergency open appendicectomy.
Presentation1.pptx
Laura Jones presents with 1 day of vomiting, abdominal pain, and fatigue. She drinks 3-4 glasses of wine per day, which has increased recently. On exam, she appears generally ill with tenderness in her abdomen. Labs show macrocytic anemia from folate deficiency, elevated pancreatic enzymes consistent with acute pancreatitis likely from alcohol use, and dehydration.
Tetralogy of Fallot.pptx
A 35-year-old male presented with cyanosis and clubbing. He has a history of breathlessness that has progressively worsened, as well as cyanosis of his fingers, toes, and lips since childhood. On examination, he was ill-looking with below average nutrition and cyanosis. He had clubbing of his fingers and toes. Echocardiography showed a peri-membranous VSD, overriding aorta, RV hypertrophy, and pulmonary valve stenosis. The final diagnosis was Tetralogy of Fallot.
HSE-BMS-046 Hypertension.ppt
Hypertension is defined as blood pressure over 140/90 and is a major health problem. It often has no symptoms, so regular blood pressure checks are important. If untreated, hypertension can lead to heart disease, stroke, kidney failure and other serious health issues. Lifestyle factors like diet, exercise, weight, and stress management are important for prevention and treatment, along with medication if needed to control blood pressure.
Physical diagnosis
The 85-year-old male patient presented with progressive forgetfulness, weight loss, and depressed mood over the past year since his wife's death. His daughter observed a decline in his ability to recall recent events, directions, and names. Alzheimer's disease is the primary consideration given his age and symptoms consistent with typical memory loss and cognitive decline seen in Alzheimer's. Differential diagnoses considered include delirium, depression, and hypothyroidism but were deemed less likely based on aspects of his history and presentation that did not fully match these conditions.
History and PE
The 85-year-old male patient presented with progressive forgetfulness, weight loss, and depressed mood over the past year since his wife's death. His daughter observed deterioration in his memory, concentration, and ability to carry on conversations. Alzheimer's disease is the primary consideration given his age and symptom progression. Differential diagnoses considered include delirium, depression, and hypothyroidism but were deemed less likely based on aspects of his clinical presentation and history.
5. PDA
KA, a 7-month-old Malay boy, was admitted to the hospital due to shortness of breath, coughing, and vomiting. On examination, he showed signs of respiratory distress including rapid breathing and recession of the ribs. Auscultation revealed widespread crackles and wheezes throughout both lungs. A provisional diagnosis of pneumonia was made, with bronchiolitis and asthma considered as differentials. Blood tests and renal function were normal.
This assignment provides the opportunity for the graduate nurse prac.docx
This assignment provides the opportunity for the graduate nurse practitioner student to become familiar with research processes which are specific to quality improvement. The graduate nursing student will develop a State of the Science Evidence-Based Practice Project that is focused on quality improvement.
Note:
The process began in Week 2 with the formation of a PICO question. Week 4 was Part 1 of the paper which laid the ground work for the project. Part 2 of the Project in Week 6 adds the following elements: Abstract, Review of the Literature (State of the Science), strengths and limitations of current evidence, and development of a quality enhancement (improvement) plan that addresses limitations of current practice evidence.
Activity Learning Outcomes
Integrate evidence-based practice and research to support advancement of holistic nursing care in diverse healthcare settings (CO1)
Integrate knowledge related to evidence-based practice and person-centered care to improve healthcare outcomes (CO2)
Develop knowledge related to research and evidence-based practice as a basis for designing and critiquing research studies (CO4)
Due Date:
Sunday by 11:59pm MT at the end of
WEEK 6
Part 1 and 2 should be submitted as the final paper
Students are expected to submit assignments by the time they are due. Assignments submitted after the due date and time will receive a deduction of 10% of the total points possible for that assignment for each day the assignment is late. Assignments will be accepted, with penalty as described, up to a maximum of three days late, after which point a zero will be recorded for the assignment. Quizzes and discussions are not considered assignments and are not part of the late assignment policy.
Total Points Possible: 200pts
Requirements:
Preparing the Assignment: Part 2 Criteria for Content
Abstract:
The abstract should be succinct, comprehensive, and follow and include these APA components (accurate, non-evaluative, coherent, readable and concise).
A description of the problem under investigation (one sentence), participants, and essential features of the quality improvement project which include setting, supporting theory, stakeholders and outcome measurements that would be used to determine efficacy of quality improvement project are included.
(See APA 6th ed., for abstract examples and explanation; p. 25-26)
State-of-the-Science Review of the Literature (ROL)
:
See Polit & Beck, 2018, 9th ed., Ch. 7 for description of ROL.
This section will describe the state of the science related to the PICO question and problem statement, purpose of the quality project.
A minimum of
6
(six) appropriate
research-based scholarly references
(articles) must be used. Required textbook for this course, dictionary and Chamberlain College of Nursing lesson information may be used but will
NOT
count as scholarly references for this assignment. For additional assistance regard.
This assignment provides the opportunity for the student to cont.docx
This assignment provides the opportunity for the student to continue development of a MSN EBP scholarly project that started with the identification of a nursing concern and PICOT/PICo question from Week 2. The focus of this assignment is to discuss the research-based literature support for the selected concern, identify an appropriate research design, explain the sampling method, and discuss implementation through the use of a change model.
Course Outcome:
This assignment enables the student to meet the following course outcome:
CO 1. Integrate evidence-based practice and research to support advancement of holistic nursing care in diverse healthcare settings. (PO 1)
CO 2. Integrate knowledge related to evidence-based practice and person-centered care to improve healthcare. (PO 2, 5)
CO #4. Develop knowledge related to research and evidence-based practice as a basis for designing and critiquing research studies. (PO 1, 2, 3, 5)
CO #5. Analyze research findings and evidence-based practice to advance holistic nursing care initiatives that promote positive healthcare outcomes. (PO 1, 2, 5)
Due Date
Sunday 11:59 PM MT at the end of Week Five
Students are given the opportunity to request an extension on assignments for emergent situations. Supporting documentation must be submitted to the assigned faculty. If the student’s request is not approved, the assignment is graded and a late penalty is applied as follows:
Monday = 10% of total possible point reduction
Tuesday = 20% of total possible point reduction
Wednesday = 30% of total possible point reduction
If the student’s request is approved, the student will be informed of the revised due date. Should the student fail to meet the revised due date, the assignment is graded and a late penalty is applied as follows:
Monday = 10% of total possible point reduction
Tuesday = 20% of total possible point reduction
Wednesday = 30% of total possible point reduction
Total Points Possible: 250 points
Requirements
Description of the Assignment:
This continues the development of a MSN EBP scholarly project by requiring the student to identify the additional elements of the process. The required elements are noted to be:
Research Literature Support (NOTE: Ten research-based references related to PICOT/PICo question are required)
Research Approach and Design
Sampling
Intervention
Criteria for Content
Research Literature Support:
In this section, comprehensive research literature support for the identified nursing concern and PCIOT/PICo question is to be provided. A minimum of
ten (10)
research-based references are required. The use of a systematic research review article as a reference is
NOT
allowed. All research studies are to be consistent with the selected concern and PICOT/PICo question. The PICOT/PICOT question is restated before presenting the research literature support. For each research-based reference the following information is to be discussed:
-Purpose of th.
More Related Content
Similar to This Assignment will assess your ability to evaluate subjective .docx
Mrs. Jones is a 32 year old Caucasian female who presents for fo.docx
A 32-year-old woman presents for follow-up for gestational diabetes. She was diagnosed with gestational diabetes during her first pregnancy 3 months ago but has not checked her blood glucose since leaving the hospital due to being busy. She has a strong family history of diabetes and was told to monitor her blood glucose after weaning from breastfeeding. On examination, she is overweight but otherwise healthy. She reports increased fatigue and difficulty sleeping.
62181184 quinx-case-study
Mrs. A, a 76-year-old woman with a history of hypertension and stroke, presented with body weakness. Her physical exam found weakness on her right side and enlarged heart on chest x-ray. Lab results showed abnormal cholesterol and electrolyte levels. She was diagnosed with uncontrolled hypertension and given medications to control her blood pressure along with dietary and lifestyle counseling upon discharge.
Soap notes will be uploaded to Moodle and put through TURN-It-In (an
Soap notes will be uploaded to Moodle and put through TURN-It-In (anti-Plagiarism program)
Turn it in Score must be less than 50% or will not be accepted for credit, must be your own work and in your own words. You can resubmit, Final submission will be accepted if less than 50%. Copy paste from websites or textbooks will not be accepted or tolerated. Please see College Handbook with reference to Academic Misconduct Statement.
Example:
PATIENT INFORMATION
Name: Mr. W.S.
Age: 65-year-old
Sex: Male
Source: Patient
Allergies: None
Current Medications: Atorvastatin tab 20 mg, 1-tab PO at bedtime
PMH: Hypercholesterolemia
Immunizations: Influenza last 2018-year, tetanus, and hepatitis A and B 4 years ago.
Surgical History: Appendectomy 47 years ago.
Family History: Father- died 81 does not report information
Mother-alive, 88 years old, Diabetes Mellitus, HTN
Daughter-alive, 34 years old, healthy
Social Hx: No smoking history or illicit drug use, occasional alcoholic beverage consumption on social celebrations. Retired, widow, he lives alone.
SUBJECTIVE:
Chief complain
: “headaches” that started two weeks ago
Symptom analysis/HPI:
The patient is 65 years old male who complaining of episodes of headaches and on 3 different occasions blood pressure was measured, which was high (159/100, 158/98 and 160/100 respectively). Patient noticed the problem started two weeks ago and sometimes it is accompanied by dizziness.He states that he has been under stress in his workplace for the last month.
Patient denies chest pain, palpitation, shortness of breath, nausea or vomiting.
ROS:
CONSTITUTIONAL
: Denies fever or chills. Denies weakness or weight loss.
NEUROLOGIC
: Headache and dizzeness as describe above. Denies changes in LOC. Denies history of tremors or seizures.
HEENT
: HEAD: Denies any head injury, or change in LOC. Eyes: Denies any changes in vision, diplopia or blurred vision. Ear: Denies pain in the ears. Denies loss of hearing or drainage. Nose: Denies nasal drainage, congestion. THROAT: Denies throat or neck pain, hoarseness, difficulty swallowing.
Respiratory
:Patient denies shortness of breath, cough or hemoptysis.
Cardiovascular
: No chest pain, tachycardia. No orthopnea or paroxysmal nocturnal
dyspnea.
Gastrointestinal
:Denies abdominal pain or discomfort.Denies flatulence, nausea, vomiting or
diarrhea.
Genitourinary
: Denies hematuria, dysuria or change in urinary frequency. Denies difficulty starting/stopping stream of urine or incontinence.
MUSCULOSKELETAL
: Denies falls or pain. Denies hearing a clicking or snapping sound.
Skin
: No change of coloration such as cyanosis or jaundice, no rashes or pruritus.
Objective Data
CONSTITUTIONAL
: Vital signs: Temperature: 98.5 °F, Pulse: 87, BP: 159/92 mmhg, RR 20, PO2-98% on room air, Ht- 6’4”, Wt 200 lb, BMI 25. Report pain 0/10.
General appearance: The patient is alert and oriented x 3. No acute distress noted.
NEUROLOGIC:
Alert, CNII-XII grossly intac ...
Soap Note Hypertension Draft.docx
1. This SOAP note is for a 65-year-old male patient who presented with headaches and high blood pressure readings over the past two weeks.
2. On examination, the patient's blood pressure was 159/92 mmHg. No other abnormalities were found.
3. The patient was diagnosed with essential (primary) hypertension. The treatment plan includes lifestyle modifications and starting hydrochlorothiazide 25 mg daily. Follow-up with his primary care provider in one week is recommended to monitor his blood pressure.
Soap Note # Main Diagnosis ( Exp H&P Note #3 DX Hypertension).docx
Soap Note # Main Diagnosis ( Exp: H&P Note #3 DX: Hypertension)
Student Name
Miami Regional University
Date of Encounter:
Preceptor/Clinical Site:
Clinical Instructor: Dr. Rafael Camejo
Soap Note #
Main Diagnosis
( Exp: Soap Note #3 DX: Hypertension)
PATIENT INFORMATION
Name
: Mr. DT
Age
: 68-year-old
Gender at Birth:
Male
Gender Identity
: Male
Source
: Patient
Allergies
: PCN, Iodine
Current Medications:
· Atorvastatin tab 20 mg, 1-tab PO at bedtime
· ASA 81mg po daily
· Multi-Vitamin Centrum Silver
PMH:
Hypercholesterolemia
Immunizations:
Influenza last 2018-year, tetanus, and hepatitis A and B 4 years ago.
Preventive Care
: Coloscopy 5 years ago (Negative)
Surgical History
: Appendectomy 47 years ago.
Family History
: Father- died 81 does not report information
Mother-alive, 88 years old, Diabetes Mellitus, HTN
Daughter-alive, 34 years old, healthy
Social History
: No smoking history or illicit drug use, occasional alcoholic beverage consumption on social celebrations. Retired, widow, he lives alone.
Sexual Orientation
: Straight
Nutrition History
: Diets off and on, Does not each seafood
Subjective Data:
Chief Complaint
: “headaches” that started two weeks ago
Symptom analysis/HPI:
The patient is 65 years old male who complaining of episodes of headaches and on 3 different occasions blood pressure was measured, which was high (159/100, 158/98 and 160/100 respectively). Patient noticed the problem started two weeks ago and sometimes it is accompanied by dizziness. He states that he has been under stress in his workplace for the last month. Patient denies chest pain, palpitation, shortness of breath, nausea or vomiting.
Review of Systems (ROS)
CONSTITUTIONAL
: Denies fever or chills. Denies weakness or weight loss.
NEUROLOGIC
: Headache and dizziness as describe above. Denies changes in LOC. Denies history of tremors or seizures.
HEENT
: HEAD: Denies any head injury, or change in LOC. Eyes: Denies any changes in vision, diplopia or blurred vision. Ear: Denies pain in the ears. Denies loss of hearing or drainage. Nose: Denies nasal drainage, congestion. THROAT: Denies throat or neck pain, hoarseness, difficulty swallowing.
RESPIRATORY
: Patient denies shortness of breath, cough or hemoptysis.
CARDIOVASCULAR
: No chest pain, tachycardia. No orthopnea or paroxysmal nocturnal
dyspnea.
GASTROINTESTINAL
: Denies abdominal pain or discomfort. Denies flatulence, nausea, vomiting or
diarrhea.
GENITOURINARY
: Denies hematuria, dysuria or change in urinary frequency. Denies difficulty starting/stopping stream of urine or incontinence.
MUSCULOSKELETAL
: Denies falls or pain. Denies hearing a clicking or snapping sound.
SKIN
: No change of coloration such as cyanosis or jaundice, no rashes or pruritus.
Objective Data:
VITAL SIGNS:
Temperature: 98.5 °F, Pulse: 87, BP: 159/92 mmhg, RR 20, PO2-98% on room air, Ht- 6’4”, Wt 200 lb, BMI 25. Report pain 2/10.
GENERAL APPREARANCE
: The patient is aler.
soap Duodenal Ulcer.docx
This soap note is for a 68-year-old male presenting with headaches and high blood pressure readings over the past two weeks. On examination, his blood pressure was elevated at 159/92 mmHg. The main diagnosis is essential (primary) hypertension. Differential diagnoses include renal artery stenosis, chronic kidney disease, and hyperthyroidism. The plan is to order labs and diagnostic tests, start antihypertensive medications, implement non-pharmacologic treatments like diet and exercise changes, and follow-up in one week to manage his blood pressure.
(Student Name) UniversityDate of EncounterPreceptorClini
(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 EncounterPreceptorClini
1. The patient is a 68-year-old male who presented with headaches and high blood pressure readings over the past two weeks. On examination, his blood pressure was elevated at 159/92 mmHg.
2. The main diagnosis is essential (primary) hypertension given the symptoms and elevated blood pressure readings with no identifiable cause found. Differential diagnoses considered include renal artery stenosis, chronic kidney disease, and hyperthyroidism.
3. Labs, diagnostic tests, pharmacologic treatment with hydrochlorothiazide and lisinopril, and non-pharmacologic recommendations including lifestyle changes and follow up in 1 week are included in the treatment plan.
Soap notes will be uploaded to Moodle and put through TURN-It-In (anti.docx
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.docx
This soap note documents a visit for a 65-year-old male patient complaining of headaches for the past two weeks. On examination, the patient's blood pressure was elevated on multiple readings. The assessment is essential (primary) hypertension. The plan includes starting hydrochlorothiazide 25 mg daily, as well as lifestyle modifications and follow up with his primary care provider in one week to evaluate blood pressure control. No referrals are needed at this time.
Pulmonary Case PresentationsPlease select one case presentation be.docx
Pulmonary Case Presentations
Please select one case presentation below and provide answers to the following;
Three differential diagnoses
Definitive diagnosis
Management plan (include appropriate treatment/diagnostic tests)
Indications for referral and/or consultations (if needed)
Health education/lifespan considerations
Schedule a F/U appointment
Case I:
50 Y/O CM present with C/O dry cough x 4-5 months with 20 year H/O tobacco use of 1PPD for 20 years. Cough has become progressively worse over the past 2-3 weeks with yellow sputum production. Took OTC cough syrup without relief of symptoms. Afebrile at home. No CP or fatigue except with excessive coughing. No HAs or head injuries. No eye pain or drainage. No ear pain or difficulty hearing. Ocass. nasal drainage of clear mucus. No sore throat or difficulty swallowing. No neck pain or stiffness. Some SOB with excessive coughing. Excessive coughing interferes with ability to perform ADLs at times. No other household members with similar symptoms.
Temp--97.2
Pulse--94
B/P 140/90
RR- 24
Pulse Ox check-- 86% on Room Air
General: Alert, apprehensive but cooperative
SKIN: W/D with rapid recoil
HEENT: Normocephalic. PERRL, sclera clear, Bil. TMs pearly gray. Boggy, pale nasal mucosa. Oropharynx without erythema or exudate
NECK: Supple without LAD (lymphadenopathy)
HEART: Tachycardia without murmur, gallops or clicks
RESP: Distant lung sounds; positive rales at base with expiratory wheezes
Case II: (mom is present and is historian)
3 Y/O Asian male present with 3 day H/O dry cough that’s worse when playing outside near Spring flowers. Took OTC cough suppressant with cough resolved but reoccurred. Afebrile at home. Positive sneezing and itchy eyes at times. Consumes fluid and solid foods without difficulty. Mom reports tiring easily when outside playing with other children in neighborhood. No SOB noted per mom. Remain active and playful. No change in urinary habits with last BM this a.m, of soft brown consistency.
Temp--98.4
Pulse--104
B/P 80/68
RR- 26
Pulse Ox check-- 95%
General: Alert, cooperative without distress.
SKIN: W/D with rapid recoil
HEENT: Normocephalic. PERRL, sclera clear, Bil.TMs pearly gray. Boggy, pale nasal mucosa. O/P without erythema, masses, or lesions. Pink, moist mucous membranes.
NECK: Supple without LAD
HEART: Regular rate and rhythm (RRR) without murmur
RESP: Expiratory wheezing without retractions or nasal flaring
ABD: Soft, round, NT with positive BS
Case III:
J. V., a 24-year-old man, is admitted to the emergency department after a motorcycle accident. He is having trouble in breathing and is very upset. The rescue personnel tell you that his breath sounds are absent on the right side, his chest expands unequally, and that there is tracheal shift toward the left. There is a large contusion on his right rib cage.
Temp--97.2
Pulse--110
B/P 140/92
RR- 28
Pulse Ox check-- 88%
General: Alert & apprehensive
SKIN: Cool & diaphoretic; bluish discoloration to right anterior thorax.
Hypertension
This document discusses hypertension including its definition, prevalence, causes, complications, evaluation, treatment goals, and lifestyle and pharmacological interventions. Some key points:
- Hypertension is defined as blood pressure over 140/90 mmHg and affects over 50 million Americans. It is a primary risk factor for heart disease and stroke.
- Accurate blood pressure measurement requires proper technique and equipment. Target organ damage from uncontrolled hypertension can affect the heart, brain, kidneys, and eyes.
- Evaluation involves assessing cardiovascular risk factors, identifying secondary causes, and checking for target organ damage. Treatment goals are blood pressure under 140/90 mmHg or 130/80 for those with diabetes or kidney disease.
- Lifestyle
HYPERTENSION (4).ppt
This document discusses hypertension including its prevalence, definition, accurate measurement, classification, secondary causes, target organ damage, evaluation, treatment goals, and lifestyle modifications. Some key points:
- Hypertension is very common, affecting over 50 million Americans. It increases risks of heart disease, stroke, and kidney disease.
- It is defined as a systolic blood pressure over 139 mmHg or diastolic over 89 mmHg based on multiple readings.
- Lifestyle changes like following the DASH diet, reducing sodium, weight loss, and exercise are effective non-pharmacological interventions. The treatment goal is a blood pressure under 140/90 mmHg or under 130/80 for those with diabetes or kidney disease.
4. Ischemic Heart Disease with Hypertension-Dr.Fatema.pptx
A 74-year-old man presented with abdominal pain, nausea, vomiting and fever for 2 days. He has a history of hypertension and ischemic heart disease treated with medications. On examination, he had tenderness in the right lower quadrant. Tests showed elevated white blood cell count and ultrasound revealed inflamed appendix with fluid in the right lower quadrant. The provisional diagnosis was acute appendicitis requiring an emergency open appendicectomy.
Presentation1.pptx
Laura Jones presents with 1 day of vomiting, abdominal pain, and fatigue. She drinks 3-4 glasses of wine per day, which has increased recently. On exam, she appears generally ill with tenderness in her abdomen. Labs show macrocytic anemia from folate deficiency, elevated pancreatic enzymes consistent with acute pancreatitis likely from alcohol use, and dehydration.
Tetralogy of Fallot.pptx
A 35-year-old male presented with cyanosis and clubbing. He has a history of breathlessness that has progressively worsened, as well as cyanosis of his fingers, toes, and lips since childhood. On examination, he was ill-looking with below average nutrition and cyanosis. He had clubbing of his fingers and toes. Echocardiography showed a peri-membranous VSD, overriding aorta, RV hypertrophy, and pulmonary valve stenosis. The final diagnosis was Tetralogy of Fallot.
HSE-BMS-046 Hypertension.ppt
Hypertension is defined as blood pressure over 140/90 and is a major health problem. It often has no symptoms, so regular blood pressure checks are important. If untreated, hypertension can lead to heart disease, stroke, kidney failure and other serious health issues. Lifestyle factors like diet, exercise, weight, and stress management are important for prevention and treatment, along with medication if needed to control blood pressure.
Physical diagnosis
The 85-year-old male patient presented with progressive forgetfulness, weight loss, and depressed mood over the past year since his wife's death. His daughter observed a decline in his ability to recall recent events, directions, and names. Alzheimer's disease is the primary consideration given his age and symptoms consistent with typical memory loss and cognitive decline seen in Alzheimer's. Differential diagnoses considered include delirium, depression, and hypothyroidism but were deemed less likely based on aspects of his history and presentation that did not fully match these conditions.
History and PE
The 85-year-old male patient presented with progressive forgetfulness, weight loss, and depressed mood over the past year since his wife's death. His daughter observed deterioration in his memory, concentration, and ability to carry on conversations. Alzheimer's disease is the primary consideration given his age and symptom progression. Differential diagnoses considered include delirium, depression, and hypothyroidism but were deemed less likely based on aspects of his clinical presentation and history.
5. PDA
KA, a 7-month-old Malay boy, was admitted to the hospital due to shortness of breath, coughing, and vomiting. On examination, he showed signs of respiratory distress including rapid breathing and recession of the ribs. Auscultation revealed widespread crackles and wheezes throughout both lungs. A provisional diagnosis of pneumonia was made, with bronchiolitis and asthma considered as differentials. Blood tests and renal function were normal.
Similar to This Assignment will assess your ability to evaluate subjective .docx (20)
Mrs. Jones is a 32 year old Caucasian female who presents for fo.docx
Mrs. Jones is a 32 year old Caucasian female who presents for fo.docx
Soap notes will be uploaded to Moodle and put through TURN-It-In (an
Soap notes will be uploaded to Moodle and put through TURN-It-In (an
Soap Note # Main Diagnosis ( Exp H&P Note #3 DX Hypertension).docx
Soap Note # Main Diagnosis ( Exp H&P Note #3 DX Hypertension).docx
(Student Name) UniversityDate of EncounterPreceptorClini
(Student Name) UniversityDate of EncounterPreceptorClini
(Student Name) UniversityDate of EncounterPreceptorClini
(Student Name) UniversityDate of EncounterPreceptorClini
Soap notes will be uploaded to Moodle and put through TURN-It-In (anti.docx
Soap notes will be uploaded to Moodle and put through TURN-It-In (anti.docx
Soap notes will be uploaded to Moodle and put through.docx
Soap notes will be uploaded to Moodle and put through.docx
Pulmonary Case PresentationsPlease select one case presentation be.docx
Pulmonary Case PresentationsPlease select one case presentation be.docx
4. Ischemic Heart Disease with Hypertension-Dr.Fatema.pptx
4. Ischemic Heart Disease with Hypertension-Dr.Fatema.pptx
More from michelle1011
This assignment provides the opportunity for the graduate nurse prac.docx
This assignment provides the opportunity for the graduate nurse practitioner student to become familiar with research processes which are specific to quality improvement. The graduate nursing student will develop a State of the Science Evidence-Based Practice Project that is focused on quality improvement.
Note:
The process began in Week 2 with the formation of a PICO question. Week 4 was Part 1 of the paper which laid the ground work for the project. Part 2 of the Project in Week 6 adds the following elements: Abstract, Review of the Literature (State of the Science), strengths and limitations of current evidence, and development of a quality enhancement (improvement) plan that addresses limitations of current practice evidence.
Activity Learning Outcomes
Integrate evidence-based practice and research to support advancement of holistic nursing care in diverse healthcare settings (CO1)
Integrate knowledge related to evidence-based practice and person-centered care to improve healthcare outcomes (CO2)
Develop knowledge related to research and evidence-based practice as a basis for designing and critiquing research studies (CO4)
Due Date:
Sunday by 11:59pm MT at the end of
WEEK 6
Part 1 and 2 should be submitted as the final paper
Students are expected to submit assignments by the time they are due. Assignments submitted after the due date and time will receive a deduction of 10% of the total points possible for that assignment for each day the assignment is late. Assignments will be accepted, with penalty as described, up to a maximum of three days late, after which point a zero will be recorded for the assignment. Quizzes and discussions are not considered assignments and are not part of the late assignment policy.
Total Points Possible: 200pts
Requirements:
Preparing the Assignment: Part 2 Criteria for Content
Abstract:
The abstract should be succinct, comprehensive, and follow and include these APA components (accurate, non-evaluative, coherent, readable and concise).
A description of the problem under investigation (one sentence), participants, and essential features of the quality improvement project which include setting, supporting theory, stakeholders and outcome measurements that would be used to determine efficacy of quality improvement project are included.
(See APA 6th ed., for abstract examples and explanation; p. 25-26)
State-of-the-Science Review of the Literature (ROL)
:
See Polit & Beck, 2018, 9th ed., Ch. 7 for description of ROL.
This section will describe the state of the science related to the PICO question and problem statement, purpose of the quality project.
A minimum of
6
(six) appropriate
research-based scholarly references
(articles) must be used. Required textbook for this course, dictionary and Chamberlain College of Nursing lesson information may be used but will
NOT
count as scholarly references for this assignment. For additional assistance regard.
This assignment provides the opportunity for the student to cont.docx
This assignment provides the opportunity for the student to continue development of a MSN EBP scholarly project that started with the identification of a nursing concern and PICOT/PICo question from Week 2. The focus of this assignment is to discuss the research-based literature support for the selected concern, identify an appropriate research design, explain the sampling method, and discuss implementation through the use of a change model.
Course Outcome:
This assignment enables the student to meet the following course outcome:
CO 1. Integrate evidence-based practice and research to support advancement of holistic nursing care in diverse healthcare settings. (PO 1)
CO 2. Integrate knowledge related to evidence-based practice and person-centered care to improve healthcare. (PO 2, 5)
CO #4. Develop knowledge related to research and evidence-based practice as a basis for designing and critiquing research studies. (PO 1, 2, 3, 5)
CO #5. Analyze research findings and evidence-based practice to advance holistic nursing care initiatives that promote positive healthcare outcomes. (PO 1, 2, 5)
Due Date
Sunday 11:59 PM MT at the end of Week Five
Students are given the opportunity to request an extension on assignments for emergent situations. Supporting documentation must be submitted to the assigned faculty. If the student’s request is not approved, the assignment is graded and a late penalty is applied as follows:
Monday = 10% of total possible point reduction
Tuesday = 20% of total possible point reduction
Wednesday = 30% of total possible point reduction
If the student’s request is approved, the student will be informed of the revised due date. Should the student fail to meet the revised due date, the assignment is graded and a late penalty is applied as follows:
Monday = 10% of total possible point reduction
Tuesday = 20% of total possible point reduction
Wednesday = 30% of total possible point reduction
Total Points Possible: 250 points
Requirements
Description of the Assignment:
This continues the development of a MSN EBP scholarly project by requiring the student to identify the additional elements of the process. The required elements are noted to be:
Research Literature Support (NOTE: Ten research-based references related to PICOT/PICo question are required)
Research Approach and Design
Sampling
Intervention
Criteria for Content
Research Literature Support:
In this section, comprehensive research literature support for the identified nursing concern and PCIOT/PICo question is to be provided. A minimum of
ten (10)
research-based references are required. The use of a systematic research review article as a reference is
NOT
allowed. All research studies are to be consistent with the selected concern and PICOT/PICo question. The PICOT/PICOT question is restated before presenting the research literature support. For each research-based reference the following information is to be discussed:
-Purpose of th.
This assignment only has to be 250-275 words.According to the .docx
This assignment only has to be 250-275 words.
According to the research (Wardle 2013; Kozol 2010) students who live in low income areas are exposed to a lower quality and/or standard of education than those in higher income areas. The research further states that students in integrated schools perform better on tests, possess increased ambitions for educational and occupational accomplishments, and lead more integrated lives as a result. Would a standardized, state-mandated curriculum work to support these students? Explain your answer, and support your response with at least one outside resource.
Additionally, who should be held accountable for this sub-par education?
The teachers who are providing guidance and instruction.
The parents whose job is to ensure their child is academically successful.
School administrators who oversee the school’s overall success.
The government that appropriates funding.
The students who should have an intrinsic value of education.
.
This assignment provides a learning activity for students to rea.docx
This assignment provides a learning activity for students to read an original research study and complete a worksheet to demonstrate understanding of the study purpose, design, sample, data collection, analysis, limitations, conclusions, and the importance of reading research literature.
Course Outcomes
This assignment enables the student to meet the following Course Outcomes.
CO1: Examine the sources of evidence that contribute to professional nursing practice. (PO 7)
CO2: Apply research principles to the interpretation of the content of published research studies. (POs 4 & 8)
CO4: Evaluate published nursing research for credibility and significance related to evidence-based practice. (POs 4, 8)
CO5: Recognize the role of research findings in evidence-based practice. (POs 7 & 8)
.
This assignment must be in APA format. The assignment shou.docx
This assignment must be in APA format.
The assignment should be in paragraph form using complete sentences and avoiding bullet points and numbered list.
Use a Level 1 heading to separate your sections (Page 47 of the APA Publication Manual).
Title and reference pages do not count toward the total word or page count.
Textbook and outside sources need to be referenced and cited in the paper.
Essays: (at least 300 words per prompt)
1. How is the Gram stain used to classify bacteria? How do antibiotics inhibit the growth of bacteria? Explain how carriers play an important role in the transmission of pathogens. Jan acquired a MRSA infection during a stay at a rehabilitation facility. Jan’s physician tells her that her MRSA was caused by S. aureus. How would you explain to Jan what S. aureus is and how it can cause diseases?
2. Lou had abdominal surgery. During his stay at the hospital a catheter was inserted into his bladder. After returning home Lou was diagnosed with a nosocomial infection. What are the principle routes of transmission of nosocomial infections? What can be done to prevent nosocomial infections? What are three reasons why rates of nosocomial infections are markedly higher in developing countries? What are five things that increase the risk of nosocomial infection?
3. What is the difference between a neoplasm, benign tumor, and malignant tumor? Identify four chronic infections that may cause cancer, and what cancer the infection might cause. Mr. Brown age 63 and Mrs. Brown age 61, are being seen in for a routine check-up. What cancer screenings should Mr. and Mrs. Brown receive (name at least 3 and why)?
4. In Western societies, why is colorectal cancer the most common cancer, but yet there has been a decline in the incidence and mortality of cervical cancer over the last 40 years? Identify and discuss four nonspecific warning signs of cancer and which cancer the warning sign is linked to. Aaron is a 28-year-old who had an EBV infection during high school. He noticed one of his lymph nodes in his neck is swollen but is not painful. He is also experiencing night sweats. What is a possible diagnosis? Give some possible treatments for this diagnosis?
.
This assignment must be completed in APA FORMAT with IN-TEXT CITATIO.docx
This assignment must be completed in APA FORMAT with IN-TEXT CITATIONS.. This paper requires a 1200 WORD REQUIREMENT and MUST include a REFERENCE PAGE. NO PLAGIARISM! This MUST be submitted to me by June 14, 2020 at 9:00am (CENTRAL TIME). THIS MUST BE SUBMITTED ON TIME! NO EXCEPTIONS!
.
This assignment measures your understanding of the correlation betwe.docx
This assignment measures your understanding of the correlation between visual systems and attention. This week you will complete a 2-3-page expository paper exploring the role of the parietal lobe in visual remapping and attentional processing.
Explore the role of the parietal lobe in visual remapping and attentional processing.
Discuss the importance of “what” and “where” in this process.
Explain how the Bottleneck theory is important in inattentional and change blindness.
.
This assignment is important because it will allow you to think ab.docx
This assignment is important because it will allow you to think about and focus on an unfamiliar ecosystem, identifying the components of living organisms. In your examination you will consider the success of the ecosystem and potential problems with the system (think man's influence, weather patterns, natural disasters).
You should spend approximately 2.5 hours on this assignment. This time includes the time to watch and review the content in the videos and complete the assignment.
Instructions
1. Using three or more of the videos you have just watched in the Exploration, choose an ecosystem and describe representatives from the following taxons:
· Microorganisms (bacteria as well as protist)
· Lower plants (e.g., fungi, moss) and higher plants (e.g., ferns, gymnosperms, angiosperms)
· Animals (lower and higher)
2. Then, in at least 250 words, respond to the following questions:
· How has this ecosystem evolved to be successful and maintain itself?
· What problems does this ecosystem face?
3. Submit your assignment to the Module 4 Assignment: Organisms, Ecosystems, and Evolution
See the Course Schedule and Course Rubrics sections in the Syllabus module for due dates and grading information.
David Bartholomae
INVENTING THE UNIVERSITY1
Education may well be, as of right, the instrument whereby every in-
dividual, in a society like our own, can gain access to any kind of
discourse. But we well know that in its distribution, in what it permits
and in what it prevents, it follows the well-trodden battle-lines of social
conflict. Every educational system is a political means of maintaining
or of modifying the appropriation of discourse, with the knowledge and
the powers it carries with it.
Foucault , "The Discourse on Language" (227)
Every time a student sits down to write for us, he has to invent
the university for the occasion-invent the university, that is, or
a branch of it, like History or Anthropology or Economics or
English. He has to learn to speak our language, to speak as we
do, to try on the peculiar ways of knowing, selecting, evaluating,
reporting, concluding, and arguing that define the discourse of
our community. Or perhaps I should say the various discourses
of our community, since it is in the nature of a liberal arts
education that a student, after the first year or two, must learn
to try on a variety of voices and interpretive schemes-to write,
for example, as a literary critic one day and an experimental
psychologist the next, to work within fields where the rules
governing the presentation of examples or the development of
an argument are both distinct and, even to a professional, mys-
terious.
The students have to appropriate (or be appropriated by) a
specialized discourse, and they have to do this as though they
David Bartholomae is Associate Professor of English and Director of Composition
at the University of Pittsburgh. He has served on the executive committees of
CCCC , WPA , and the.
This assignment may be completed as a written script. First, sum.docx
This assignment may be completed as a written script.
First, summarize how technology has changed the work of law enforcement professionals in the past two to three decades. Consider new types of crime or ways crimes are committed and how criminals are found, arrested and prosecuted.
What ethical issues have resulted from technology? Provide examples of these issues. If you were asked to prepare a code of ethics related to technology, what would it include and why are these inclusions important?
1. Technology Changes in Law Enforcement
Clearly and fully summarizes technology changes in law enforcement
2. Clearly and fully identifies ethical issues related to technology for law enforcement professionals
3. Provides at least one clear example for each ethical issue provided related to technology and law enforcement
4. Clearly and fully identifies the components of a personal ethical code
5. Clearly and fully explains the ethical reasons for the personal ethical technology code inclusions
Written papers or scripts should be a minimum of two pages.
.
This assignment is your final exam. So take your time, and do we.docx
This assignment is your final exam. So take your time, and do well. I am asking you to write an essay (remember what an essay it: introduction, body, conclusion) on how three of the epics fulfill the conventions of the epic poem. Note, don't just say, for instance, that the Odyssey contains the hero's journey. Be specific and give example from the literature. What journey did Odysseus take, and how is that journey a fulfillment of the conventions of the genre.
I suggest that you first, pick your three works, review them, plan your writing, draft, and type in another document, in Word for instance so that you can go back and make revisions and corrections.
.
This assignment is part of the continuing Project Management Project.docx
This assignment is part of the continuing Project Management Project that we have been working on. This section is the Communication Management Plan. The C
ommunications Management Plan will include the following components:
Communications Planning
Information Distribution
Performance Reporting
Managing Stakeholders
As this is a group project portions of the plan are distributed and I have been assigned the portion of Communication Planning and that is what I need you to do. Please find the charter below and make sure that the plan in accordance with the charter. Please feel free to contact me with any questions prior to completing the assignment. The assignment needs to be completed by 6pm (Eastern Standard Time) this evening so that I can submit.
Thanks for your assistance!
.
This assignment is in response to the Request for Proposals. Thi.docx
This assignment is in response to the Request for Proposals. This document will be two pages, single-spaced, and clearly written. The prospectus will have at least these sections – Introduction, Statement of Work to be Accomplished, Sequence of Steps to be Followed, Timeline, List of Deliverables, Summary Budget, and References.
Additionally, a one-page explanation of the design team will be included that gives:
Team Name(DBA Name)
List of Team Members and Roles
Listing of Experience
.
This assignment is listed as Annotated Bibliography. Your pape.docx
This assignment is listed as "Annotated Bibliography". Your paper will be an annotated bibliography, specifically focusing on the topic of using the information and communications technology for policymaking. The papers you select must address how Information Technology is used to model behavior for policymaking.
An annotated bibliography is a list of citations to books, articles, and documents. Each citation is followed by a brief (usually about 150 -200 words) descriptive and evaluative paragraph, the annotation. The purpose of the annotation is to inform the reader of the relevance, accuracy, and quality of the sources cited. A separate reference page is
NOT
required.
Your paper must be in correct APA format, use correct grammar, and will need to include at least five (5) resources, ALL of which must:
1) Be current. Published within the last five years.
2) Be peer-reviewed.
3) Relate directly to using the information and communications technology for policymaking. The papers you select must address how IT is used to model behavior for policymaking.
.
This assignment is to make Tower defense microgame using Unity. .docx
This assignment is to make Tower defense microgame using Unity.
You can just make a simple tower game.
Also you have to give me two files when you are done.
First one is the intermediate result report. The report makes sure to put them in a document with some screenshots of your code and the Unity Editor so I can see what is going on.
Second one is the zip file of the completed tower defense game files using Unity.
so, you give me one document file and one zip file that I explain
.
This assignment is separate from your course project. An importa.docx
This assignment is separate from your course project. An important task that leaders perform is setting the tone of an organization. Tone, climate, and culture are several ways that organizational experts talk about the organizational atmosphere, values, beliefs, and norms that can contribute to or hinder productivity in organizations. Various “tones” can be a part of the organizational setting, including trust, mistrust, hope, despair, faith, fear, conflict, and many more.
For this assignment, observe two actual, different leaders in your life as they conduct a meeting, practice, class, or other group activity. As you observe the event, consider the following questions:
How did the leader make goals clear to group members?
How were different members and their talents utilized?
What were some of the positive norms of the group? Negative norms? How did the leader contribute to or reinforce those norms?
How would you assess the cohesiveness of the group?
What are your observations of the general tone and climate of the meeting? How did the leader contribute to or reinforce the tone (Northouse, 2009, pp. 120– 121)?
After you have observed the two meetings and considered the reflective questions above, write a summary of your findings. In particular:
Compare and contrast the two leaders’ tone setting style. Focus on the people issues.
How did the leaders’ different tone setting style seem to contribute to the norms, reactions, climate, and group outcomes?
Additionally:
Assess your own tone-setting style.
Evaluate what you can learn and apply from your observations of the leaders and from the organizational literature to enhance your tone-setting style.
Submit your report as a 3- to 5-page Microsoft Word document, using APA style
***Use a scholarly source in EACH PARAGRAPH***
Book References
Hughes, R. L., Beatty, K. C., & Dinwoodie, D. L. (2014).
Becoming a Strategic Leader: Your Role in Your Organization's Enduring Success
(2nd ed.).
San Francisco, CA: Jossey-Bass. 978-1-118-56723-4
Kouzes, J. M., & Posner, B. Z. (2017).
The Leadership Challenge
, (6th ed.)
. San Francisco, CA: Wiley. 9781119278962
.
This assignment is not the full paper. The topic is Ford (not Me.docx
This assignment is not the full paper.
The topic is Ford (not Merck)
Submission Details:
Review the sample outline. Please use this sample as a guide for expectations in terms of writing and flow of content.
Follow the complete APA style of writing to include a title page with a running head, body, conclusion, and reference list.
.
This assignment is taken from page 17 of Russell Willertons Plain.docx
This assignment is taken from page 17 of Russell Willerton's
Plain Language and Ethical Action: A Dialogic Approach to Technical Content in the 21st Century
(in UHD e-library). Read the chapter and then think of a BUROC situation that you have faced. What was the situation? Which parts of the BUROC situation were most salient or prominent in the situation? What information did you get, and how was it used? How did you respond to the situation, and how do you feel now as you reflect on the situation?
.
This assignment is not due until Week Six (Sunday, April 11), .docx
This assignment is not due until
Week Six
(
Sunday, April 11), and it is worth 150 points
Click on the link below to submit your work as a .ppt or .pptx file.
Do not send the file by any other via; use only this link.
What the assignment consists of:
You must identify the everyday details that illustrate your unique family and cultural communities. You will share personal and cultural details which include:
1. family pictures,
2. your birthplace, Cuba
3. description of your home (physical characteristics),
4. birthplace of your parents, cuba
5. names of family members, mother- aileen Lazo father- Dagoberto Perez-brother Santiago Perez- sister Daimy Perez. grandparents- Santiago, deisy and Maritza
6. languages you are surrounded with (what you hear and speak on a daily basis), Spanish
7. common sayings by parents and grandparents (words of wisdom shared with you),
8. everyday items (things you use every day),
9. everyday foods, rise and beans
10. foods for special occasions, spaghetti
11. type of music enjoyed, cuban music
12. family stories. came from cuba when I was 12 years old with my mother and brother and my dad had to stay and he came 6b months later, HARD TIME, first time I was without my father for so long.
Using photos in digital form, you will create a slideshow or PowerPoint
(more than 15 slides
) in order to share your cultural heritage.
You do not have to write an essay about the topic, just create the slideshow with text and images.
Remember to include real pictures of you and your family.
If while in the process of preparing the project you have any questions/concerns, please do not hesitate to contact me.
DO NOT wait until the due date to send the project.
Remember you will have three (3) weeks to submit it; therefore, there is no reason for anyone to turn it in late.
I will NOT accept any late submissions.
.
This assignment is multiple parts, but you will be turning in on.docx
This assignment is multiple parts, but you will be turning in one document.
1. Choose
four
assessments that demonstrate the integration of assessment into instruction to promote the learning of all students. These assessments must give strong evidence of designing, selecting, and employing a wide variety of formal and informal assessment tools to match educational purposes.
These assessments should show student work and clear evidence through marking up that you are helping students develop self-assessment skills and are encouraging them to reflect on their performances. Research supports the notion that teacher markups on assessments greatly improves student learning.
Please remove or black out students’ names from the assessment before scanning, copying or photographing. You need to choose three formative assessments and one summative assessment.
2. Complete a write-up (2-4 pages) for each of the four assessments. The write up of each assessment must include:
the lesson context, the assessment description,
why this particular assessment was chosen (you may mention research basis here),
what the teacher and student learned from the assessment,
how the assessment impacted unique student’s learning?
You may submit all of the write-ups separately or copy/paste them into one document. Once you have completed your write-ups, please
submit them.
.
This assignment is intended to help you use leadership skills to.docx
This assignment is intended to help you use leadership skills to gather project members from cross-functional departments and skill sets and lead them in the fulfillment and implementation of a mock project.
Discover
the various responsibilities of a project manager by organizing a project. See Chapter 19, sections 19.9 and Cases.
Apply
project management tools and a PM outline type of your choice to structure and plan the project by defining, planning, and controlling. The project will be a continuation of how to improve the process you chose in Weeks 1 and 2.
Create
a 10- to 12-slide PowerPoint (supported by Excel and Word as needed) presentation, with detailed speaker notes, that includes the following:
Project description
Project Management Charts (Critical Path, Gant Chart, etc.)
Improved Process Flow Chart from Week 1
Meeting cadence/rhythm and timing
Metrics to measure the project’s success
Financial and budgetary considerations
Description of the project reporting structure
Cite
references to support your assignment.
Format
your assignment according to APA guidelines.
.
More from michelle1011 (20)
This assignment provides the opportunity for the graduate nurse prac.docx
This assignment provides the opportunity for the graduate nurse prac.docx
This assignment provides the opportunity for the student to cont.docx
This assignment provides the opportunity for the student to cont.docx
This assignment only has to be 250-275 words.According to the .docx
This assignment only has to be 250-275 words.According to the .docx
This assignment provides a learning activity for students to rea.docx
This assignment provides a learning activity for students to rea.docx
This assignment must be in APA format. The assignment shou.docx
This assignment must be in APA format. The assignment shou.docx
This assignment must be completed in APA FORMAT with IN-TEXT CITATIO.docx
This assignment must be completed in APA FORMAT with IN-TEXT CITATIO.docx
This assignment measures your understanding of the correlation betwe.docx
This assignment measures your understanding of the correlation betwe.docx
This assignment is important because it will allow you to think ab.docx
This assignment is important because it will allow you to think ab.docx
This assignment may be completed as a written script. First, sum.docx
This assignment may be completed as a written script. First, sum.docx
This assignment is your final exam. So take your time, and do we.docx
This assignment is your final exam. So take your time, and do we.docx
This assignment is part of the continuing Project Management Project.docx
This assignment is part of the continuing Project Management Project.docx
This assignment is in response to the Request for Proposals. Thi.docx
This assignment is in response to the Request for Proposals. Thi.docx
This assignment is listed as Annotated Bibliography. Your pape.docx
This assignment is listed as Annotated Bibliography. Your pape.docx
This assignment is to make Tower defense microgame using Unity. .docx
This assignment is to make Tower defense microgame using Unity. .docx
This assignment is separate from your course project. An importa.docx
This assignment is separate from your course project. An importa.docx
This assignment is not the full paper. The topic is Ford (not Me.docx
This assignment is not the full paper. The topic is Ford (not Me.docx
This assignment is taken from page 17 of Russell Willertons Plain.docx
This assignment is taken from page 17 of Russell Willertons Plain.docx
This assignment is not due until Week Six (Sunday, April 11), .docx
This assignment is not due until Week Six (Sunday, April 11), .docx
This assignment is multiple parts, but you will be turning in on.docx
This assignment is multiple parts, but you will be turning in on.docx
This assignment is intended to help you use leadership skills to.docx
This assignment is intended to help you use leadership skills to.docx
Recently uploaded
Exploiting Artificial Intelligence for Empowering Researchers and Faculty, In...
Exploiting Artificial Intelligence for Empowering Researchers and Faculty, In...Dr. Vinod Kumar Kanvaria
Exploiting Artificial Intelligence for Empowering Researchers and Faculty,
International FDP on Fundamentals of Research in Social Sciences
at Integral University, Lucknow, 06.06.2024
By Dr. Vinod Kumar KanvariaNatural birth techniques - Mrs.Akanksha Trivedi Rama University
Natural birth techniques - Mrs.Akanksha Trivedi Rama UniversityAkanksha trivedi rama nursing college kanpur.
Natural birth techniques are various type such as/ water birth , alexender method, hypnosis, bradley method, lamaze method etcPengantar Penggunaan Flutter - Dart programming language1.pptx
Pengantar Penggunaan Flutter - Dart programming language1.pptx
How to deliver Powerpoint Presentations.pptx
"How to make and deliver dynamic presentations by making it more interactive to captivate your audience attention"
How to Make a Field Mandatory in Odoo 17
In Odoo, making a field required can be done through both Python code and XML views. When you set the required attribute to True in Python code, it makes the field required across all views where it's used. Conversely, when you set the required attribute in XML views, it makes the field required only in the context of that particular view.
How to Build a Module in Odoo 17 Using the Scaffold Method
Odoo provides an option for creating a module by using a single line command. By using this command the user can make a whole structure of a module. It is very easy for a beginner to make a module. There is no need to make each file manually. This slide will show how to create a module using the scaffold method.
BÀI TẬP BỔ TRỢ TIẾNG ANH 8 CẢ NĂM - GLOBAL SUCCESS - NĂM HỌC 2023-2024 (CÓ FI...
BÀI TẬP BỔ TRỢ TIẾNG ANH 8 CẢ NĂM - GLOBAL SUCCESS - NĂM HỌC 2023-2024 (CÓ FI...Nguyen Thanh Tu Collection
https://app.box.com/s/y977uz6bpd3af4qsebv7r9b7s21935vdHow to Setup Warehouse & Location in Odoo 17 Inventory
In this slide, we'll explore how to set up warehouses and locations in Odoo 17 Inventory. This will help us manage our stock effectively, track inventory levels, and streamline warehouse operations.
Walmart Business+ and Spark Good for Nonprofits.pdf
"Learn about all the ways Walmart supports nonprofit organizations.
You will hear from Liz Willett, the Head of Nonprofits, and hear about what Walmart is doing to help nonprofits, including Walmart Business and Spark Good. Walmart Business+ is a new offer for nonprofits that offers discounts and also streamlines nonprofits order and expense tracking, saving time and money.
The webinar may also give some examples on how nonprofits can best leverage Walmart Business+.
The event will cover the following::
Walmart Business + (https://business.walmart.com/plus) is a new shopping experience for nonprofits, schools, and local business customers that connects an exclusive online shopping experience to stores. Benefits include free delivery and shipping, a 'Spend Analytics” feature, special discounts, deals and tax-exempt shopping.
Special TechSoup offer for a free 180 days membership, and up to $150 in discounts on eligible orders.
Spark Good (walmart.com/sparkgood) is a charitable platform that enables nonprofits to receive donations directly from customers and associates.
Answers about how you can do more with Walmart!"
BBR 2024 Summer Sessions Interview Training
Qualitative research interview training by Professor Katrina Pritchard and Dr Helen Williams
বাংলাদেশ অর্থনৈতিক সমীক্ষা (Economic Review) ২০২৪ UJS App.pdf
বাংলাদেশের অর্থনৈতিক সমীক্ষা ২০২৪ [Bangladesh Economic Review 2024 Bangla.pdf] কম্পিউটার , ট্যাব ও স্মার্ট ফোন ভার্সন সহ সম্পূর্ণ বাংলা ই-বুক বা pdf বই " সুচিপত্র ...বুকমার্ক মেনু 🔖 ও হাইপার লিংক মেনু 📝👆 যুক্ত ..
আমাদের সবার জন্য খুব খুব গুরুত্বপূর্ণ একটি বই ..বিসিএস, ব্যাংক, ইউনিভার্সিটি ভর্তি ও যে কোন প্রতিযোগিতা মূলক পরীক্ষার জন্য এর খুব ইম্পরট্যান্ট একটি বিষয় ...তাছাড়া বাংলাদেশের সাম্প্রতিক যে কোন ডাটা বা তথ্য এই বইতে পাবেন ...
তাই একজন নাগরিক হিসাবে এই তথ্য গুলো আপনার জানা প্রয়োজন ...।
বিসিএস ও ব্যাংক এর লিখিত পরীক্ষা ...+এছাড়া মাধ্যমিক ও উচ্চমাধ্যমিকের স্টুডেন্টদের জন্য অনেক কাজে আসবে ...
PCOS corelations and management through Ayurveda.
This presentation includes basic of PCOS their pathology and treatment and also Ayurveda correlation of PCOS and Ayurvedic line of treatment mentioned in classics.
RHEOLOGY Physical pharmaceutics-II notes for B.pharm 4th sem students
Physical pharmaceutics notes for B.pharm students
Wound healing PPT
This document provides an overview of wound healing, its functions, stages, mechanisms, factors affecting it, and complications.
A wound is a break in the integrity of the skin or tissues, which may be associated with disruption of the structure and function.
Healing is the body’s response to injury in an attempt to restore normal structure and functions.
Healing can occur in two ways: Regeneration and Repair
There are 4 phases of wound healing: hemostasis, inflammation, proliferation, and remodeling. This document also describes the mechanism of wound healing. Factors that affect healing include infection, uncontrolled diabetes, poor nutrition, age, anemia, the presence of foreign bodies, etc.
Complications of wound healing like infection, hyperpigmentation of scar, contractures, and keloid formation.
How to Create a More Engaging and Human Online Learning Experience
How to Create a More Engaging and Human Online Learning Experience Wahiba Chair Training & Consulting
Wahiba Chair's Talk at the 2024 Learning Ideas Conference. Leveraging Generative AI to Drive Nonprofit Innovation
In this webinar, participants learned how to utilize Generative AI to streamline operations and elevate member engagement. Amazon Web Service experts provided a customer specific use cases and dived into low/no-code tools that are quick and easy to deploy through Amazon Web Service (AWS.)
Recently uploaded (20)
Exploiting Artificial Intelligence for Empowering Researchers and Faculty, In...
Exploiting Artificial Intelligence for Empowering Researchers and Faculty, In...
Natural birth techniques - Mrs.Akanksha Trivedi Rama University
Natural birth techniques - Mrs.Akanksha Trivedi Rama University
Pengantar Penggunaan Flutter - Dart programming language1.pptx
Pengantar Penggunaan Flutter - Dart programming language1.pptx
How to Build a Module in Odoo 17 Using the Scaffold Method
How to Build a Module in Odoo 17 Using the Scaffold Method
Digital Artefact 1 - Tiny Home Environmental Design
Digital Artefact 1 - Tiny Home Environmental Design
BÀI TẬP BỔ TRỢ TIẾNG ANH 8 CẢ NĂM - GLOBAL SUCCESS - NĂM HỌC 2023-2024 (CÓ FI...
BÀI TẬP BỔ TRỢ TIẾNG ANH 8 CẢ NĂM - GLOBAL SUCCESS - NĂM HỌC 2023-2024 (CÓ FI...
How to Setup Warehouse & Location in Odoo 17 Inventory
How to Setup Warehouse & Location in Odoo 17 Inventory
Walmart Business+ and Spark Good for Nonprofits.pdf
Walmart Business+ and Spark Good for Nonprofits.pdf
বাংলাদেশ অর্থনৈতিক সমীক্ষা (Economic Review) ২০২৪ UJS App.pdf
বাংলাদেশ অর্থনৈতিক সমীক্ষা (Economic Review) ২০২৪ UJS App.pdf
RHEOLOGY Physical pharmaceutics-II notes for B.pharm 4th sem students
RHEOLOGY Physical pharmaceutics-II notes for B.pharm 4th sem students
How to Create a More Engaging and Human Online Learning Experience
How to Create a More Engaging and Human Online Learning Experience
Leveraging Generative AI to Drive Nonprofit Innovation
Leveraging Generative AI to Drive Nonprofit Innovation
This Assignment will assess your ability to evaluate subjective .docx
- 1. This Assignment will assess your ability to evaluate subjective and objective information in order to arrive at an appropriate diagnosis and treatment plan for the patient. Hypertension Case Study C.D is a 55-year-old African American male who presents to his primary care provider with a 2-day history of a headache and chest pressure. PMH Allergic Rhinitis Depression Hypothyroidism Family History Father died at age 49 from AMI: had HTN Mother has DM and HTN Brother died at age 20 from complications of CF Two younger sisters are A&W Social History The patient has been married for 25 years and lives with his wife and two children. The patient is an air traffic controller at the local airport. He has smoked a pack of cigarettes a day for
- 2. the past 15 years. He drinks several beers every evening after work to relax. He does not pay particular attention to sodium, fat, or carbohydrates in the foods he eats. He admits to “salting almost everything he eats, sometimes even before tasting it.” He denies ever having dieted or exercised. Medications Zyrtec 10 mg daily Allergies Penicillin ROS States that his overall health has been fair to good during the past year. Weight has increased by approximately 30 pounds in the last 12 months. States he has been having some occasional chest pressure and headaches for the past 2 days. Shortness of breath at rest, headaches, nocturia, nosebleeds, and hemoptysis. Reports some shortness of breath with activity, especially when climbing stairs and that breathing difficulties are getting worse. Denies any nausea, vomiting, diarrhea, or blood in stool. Self treats for occasional right knee pain with OTC Ibuprofen. Denies any genitourinary symptoms. Vital Signs
- 3. B/P 190/120, HR 73, RR 18, T. 98.8 F., Ht 6’1”, Wt 240 lbs. HEENT TMs intact and clear throughout No nasal drainage No exudates or erythema in oropharynx PERRLA Funduscopy reveals mild arteriolar narrowing without nicking, hemorrhages, exudates, or papilledema Neck Supple without masses or bruits Thyroid normal No lymphadenopathy Lungs Mild basilar crackles bilaterally No wheezes Heart RRR No murmurs or rubs
- 4. Abdomen Soft and non-distended No masses, bruits, or organomegaly Normal bowel sounds Ext Moves all extremities well Neuro No sensory or motor abnormalities CN’s II-XII intact DTR’s = 2+ Muscle tone=5/5 throughout What you should do: Develop an evidence-based management plan. Include any pertinent diagnostics. Describe the patient education plan. Include cultural and lifespan considerations. Provide information on health promotion or health care maintenance needs.
- 5. Describe the follow-up and referral for this patient. Prepare a 3–5-page paper (not including the title page or reference page). Your writing Assignment should: follow the conventions of Standard English (correct grammar, punctuation, etc.); be well ordered , logical , and unified , as well as original and insightful ; display superior content, organization, style, and mechanics ; and use APA 6th Edition format as outlined in the APA Progression Ladder .
- 6. I NEED THIS ASSIGNMENT TODAY. THANK YOU