SOAP Note and Differential Diagnoses for iHuman Case. EOMs intact. I know that normal is used in chartingbut you are learning and so you are required to do the ideal and the ideal is describing what you see and completing a total ROS on every patient. Bladder is non-distended; no CVA tenderness. Therefore, any of the symbols found on these symbol pages can be used for historical Daily charts with those Trading services. Dressed in clean slacks, shirt and coat. Cervix is pink. Describe the course of the patients illness, including when it began, character of symptoms, location where the symptoms began, aggravating or alleviating factors; pertinent positives and negatives, other related diseases, past illnesses, surgeries or past diagnostic testing related to present illness. SOAP Note and Differential Diagnoses for iHuman Case. Full ROM; no cervical lymphadenopathy; no occipital nodes. S1, S2 with regular rate and rhythm. Please note we do not have prewritten answers. Retrieved from https://digitalbookshelf.southuniversity.edu/#/books/9780826168757/. Dressed in clean slacks, shirt and coat. Reason given by the patient for seeking medical care in quotes. Ours isnt a collection of individuals who are good at searching for information on the Internet and then conveniently re-writing the information obtained to barely beat Plagiarism Software. Genitourinary: Bladder is non-distended; no CVA tenderness. Clear to auscultation with no adventitous sounds bilaterally. Table of Content. Anyone diagnosed with: lung disease, heart disease, htn, cancer, TB, DM, or kidney disease. External genitalia reveals coarse pubic hair in normal distribution; skin color is consistent with general pigmentation.No uretheral discharge. Philadelphia, PA: F.A. Pulses 3+ throughout. Respiratory: Symmetric chest wall. In 1967, he moved to . The reference may come from a journal, a book, etc. The HPI is one of them. Eyes: PERRLA. Our writers are also not the kind to decorate articles with unnecessary filler words. Neck: Supple. Gastrointestinal: Abdomen flat; BS hyper active in all 4 quadrants. He states the patin is often as 8 or 10 out of 10 severity. No nail pitting or clubbing. You would not leave these in an official SOAP note. Genitourinary: Bladder is non-distended; no CVA tenderness. Reason given by the patient for seeking medical care in quotes. The scrotum is swollen on left side. Great! Teeth are in good repair. You can contact our live agent via WhatsApp +1(209)962-2652, Reflective Analysis: Risk Management and the Role of Managed Care. Avoid contact with infants, children, pregnant women, and adults who have never had chicken pox, until blisters are completely dry. He is not in distress. Nutrition: recommending better choices when eats out (Buttaro, Trybulski & Bailey, 2013). Dressed in clean slacks, shirt and coat. : Mosby/Elsevier. Jack Baldwin V3 PC (Basic DDx) 50 years 6' 0" 180 pounds Jack Baldwin Chief complaint: Groin pain Start differential diagnosis and final diagnosis . I love going to iHuman. Epididymitis: fever, Swelling and tenderness of the scrotum (usually located on one side), patient may get relief with elevation of scrotum, which is positive Prehns sign. Full ROM; no cervical lymphadenopathy; no occipital nodes. Flu shot in October 2012 and plans to get the Flu vaccine this year. Treatment of kidney stone includes: pain management such as ibuprofen (Motrin, Advil), Zofran 4mg every 6 hours as needed for controlling nausea/vomiting, helping with passing the stone by using Tamsulosin (Flomax) 0.4mg daily to ease urination (Buttaro, Trybulski & Bailey, 2013). Hernia inguinal K40 (ICD-10 Code Lookup, 2016). Good tone. Sir Jack E. Baldwin FRS (August 8, 1938- January 4, 2020) Born in London, Baldwin conducted his undergraduate and graduate studies at Imperial College with Nobel Laureate Sir Derek Barton (who described him as his best student), and received his PhD in 1964. Full ROM; no cervical lymphadenopathy; no occipital nodes. (2014). Patient has been controlling pain with Tylenol 650 mg PO and he states it helps moderately. Step 2 Abdomen obese; BS active in all 4 quadrants. He states the patin is often as 8 or 10 out of 10 severity. Alert and oriented. Height: 60 Pulse: 130bmp (tachycardia) RR: 18bpm, oxygen saturation is 98%, RA. Have you every been told that you have: Diabetes, HTN, peptic ulcer disease, asthma, lung disease, heart disease, cancer, TB, thyroid problems or kidney disease or psychiatric diagnosis.. Cash, J. C. (2014). Surgery is an effective treatment, laparoscopy or through an open procedure or mesh repair depending the size of the hernia, and the onset of strangulation. Does not cross midline. We accept MasterCard, Visa, Amex and Discover. HEENT: Head is normocephalic, atraumatic and without lesions; hair evenly distributed. Goolsby, M. J., & Grubbs, L. (2015). (2013). In CMS.gov. The testicles are normal in size and nontender to palpation. ORDER A CUSTOM-WRITTEN, PLAGIARISM-FREE PAPER HERE Provide a subjective, objective, assessment, and plan (SOAP) note on this patient and your treatment plan using the SOAP note template. This week, complete the iHuman case titled " Buddy (Theodore, Jr.) VE ." Bladder is non-distended; no CVA tenderness. He makes eye contact and responds to questions appropriately. Jack Baldwin VE iHuman Episodic SOAP Note and Differential Diagnoses Examples. Housing: Condominium Occupation: Accountant Tobacco use: Smokes 1 ppd; Alcohol: 1 to 2 drinks/day; History of: narcotic abuse (Percocet) Sexual history: Monogamous Jack Baldwin VE iHuman Episodic SOAP Note and Differential Diagnoses Examples, General(-) Fatigue, (-) weight loss, (-) chills, (-) fever, (-) night sweats, (-) change in energy level, Skin(-) delayed healing, (-) rashes, (-) bruising, (-) bleeding or skin discolorations, (-) any changes in lesions or moles, Eyes(-) Corrective lenses, (-) blurring,(-) change in vision Ears(-) ear pain, (-) hearing loss, (-) dischargeNose/Mouth, Throat(-) Sinus problems, (-) dysphagia, (-) nose bleeds or discharge, (-)dental disease, (-) hoarseness, (-) throat pain, Heme/Lymph/Endo (-)HIV, (-) blood transfusion hx(-), cold intolerance, (-) bruising, (-) night sweats, (-) increase hunger/thirst, Cardiovascular(-) chest pain, (-) palpitations, (-) edema, (-) PND, (-) orthopnea Respiratory(-) cough, (-) wheeze, (-) hemoptysis, (-) dyspnea, (-) pneumonia hx, (-) TB, Gastrointestinal(-) Abdominal pain, (+) Nausea, (+) vomiting, diarrhea(-), (-) constipation, (-) hepatitis, (-) hemorrhoids, (-)eating disorders, (-) ulcers, (-) black tarry stools, Genitourinary/Gynecological:(-) urgency, (-) frequency, (-) hesitancy, (-) dysuria, (-) hematuria (+) sexual activity, (-) STDS, Rectal Denies any bleeding or pain Musculoskeletal(-) back pain, (-) swelling of joints, (-) fracture historyNeurologicalDenies weakness or numbness, (-) headache, (-) Syncope, (-) seizures, (-) transient paralysis, (-) weakness, (-) paresthesias, (-) black out spells, Psychiatric(-) depression, (-) anxiety, (-) sleeping difficulties, (-) suicidal ideation/attempts, (-) previous dx, Weight: 180.0 lbs. No adnexal masses or tenderness. There is tenderness within the left inguinal canal; right inguinal canal normal. Right side normal. Discuss the pathophysiology of this disease process/condition. Teeth are in good repair. (Male: both testes palpable, no masses or lesions, no hernia, no uretheral discharge. Maintains eye contact. Tetanus booster vaccine in 2010. Anyone diagnosed with: lung disease, heart disease, htn, cancer, TB, DM, or kidney disease. Today. Jack Baldwin (American football) John David Baldwin (July 31, 1921 - September 13, 1989) was an American football player who played at the center and linebacker positions. Teeth are in good repair. Dressed in clean slacks, shirt and coat. Tactile fremitus equal bilaterally. He makes eye contact and responds to questions appropriately. No extra sounds, clicks, rubs or murmurs. Just request for our write my paper service, and we\'ll match you with the best essay writer in your subject! Prostrate is smooth, non-tender and free from nodules, is of normal size, sphincter tone is firm. Even though the patient is monogamous, it was important to better understand the relationship of the patient with close family members (Dains, Baumann, & Scheibel, 2015). A:P / 2:1. Once youve submitted your writing requests, you can go take a stroll while waiting for our all-star team of writers and editors to submit top quality work. Jack Baldwin VE iHuman Episodic SOAP Note - School Academy . Baldwin was born in Barking, Greater London. Healthy appearing adult female in no acute distress. You also neednt worry about logical flow of thought, sentence structure as well as proper use of phrases. Students can be assigned cases individually, in a lecture, a flipped classroom or in a team-based learning environment. Neurological: Speech clear. Use this week's iHuman case titled "Jack Baldwin VE" and create a SOAP note with a treatment plan (located at the bottom of the SOAP note. Skin: Warm, diaphoresis, (-) Delayed healing, (-) rashes, (-) bruising, (-) bleeding or skin discolorations, (-)any changes in lesions or moles No. Evidenced by Inguinal or scrotal nonreducible mass with severe pain, vomiting, and constipation and scrotal ultrasound result (Fischbach & Dunning, 2014). Home Symmetric chest wall. Patient reports having chicken pox when he was age 5. Otherwise no complaints at this time. Patients states he now feels a constant sharp, burning pain in the area. Good tone. Note: For purposes of this sample SOAP note comments on what is required for each section have been left in place. The testicles are normal in size and nontender to palpation. General Appearance: A healthy appearing adult male with acute distress. Support-Chat with us today! No relevant social history; denies use of tobacco, alcohol, or illicit drugs. Jack Baldwin VE iHuman Episodic SOAP Note and Differential Diagnoses Examples, o 1- Herpes zoster without mention of complication (053.9) o 2- Rash and other nonspecific skin eruption (782.1) o 3- Other malaise and fatigue (780.79), Presumptive Diagnosis o 1- Herpes zoster without mention of complication (053.9), Diagnois:Herpes zoster without mention of complication (053.9), Medication: Valtrex 1000 mg PO q8h X 7 days, Education: Continue using Tylenol 650 mg PO to manage pain. Breast is free from masses or tenderness, no discharge, no dimpling, wrinkling or discoloration of the skin. Eyes: PERRLA. Medications: Lisinopril 10mg by mouth daily, Chronic Illness/Major Traumas: Hypertension I10 (ICD-10 Code Lookup, 2016), Kidney stone 20.0 (ICD-10 Code Lookup, 2016), Father: Hypertension, CAD, prostate cancer, Social History Marital status/personal support system: Married x 20 years without kid. Educate patient to avoid heavy lifting, and gently reduce a groin hernia when the individual lies supine with hips flexed to relax the abdominal muscles (Cash, 2014). It may take up to six weeks for the raash to completely heal. Related Questions and Answers. Abdomen soft, non-tender. Otherwise no complaints at this time. Ovaries are non-palpable. Balance stable; gait normal. NSG 6020 Week 9 Discussion.docx South University assessment NSG 6020 - Fall 2019 . ORDER A CUSTOM-WRITTEN, PLAGIARISM-FREE PAPER HERE Posture erect. Safety meaures:Patient states I always wear my seatbelt. Alert and oriented. 34 year old male presents to office with a linear vesicular rash to the right side of his back. Vesicles may burst and then crust over. No other lesions, bruises, or suspicious moles present. Denies any heat or cold intolerance, thyroid enlargement or tenderness, unexpected weight changes, or abnormal distribution in body hair. Balance stable; gait normal. BMI: 24.4 Temp: 99 (Oral)BP: 170/94. That's called the flank, right? Musculoskeletal: Full ROM seen in all 4 extremities as patient moved about the exam room. Neck: Supple. They are also well versed with citation styles such as APA, MLA, Chicago, Harvard, and Oxford which come handy during the preparation of academic papers. Full ROM; no cervical lymphadenopathy; no occipital nodes. Fitness: encouraging increasing exercise (Buttaro, Trybulski & Bailey, 2013). Patient has been controlling pain with Tylenol 650 mg PO and he states it helps moderately. The HPI is one of them. Respiratory: Symmetric chest wall. Speech is soft, though clear and of normal rate and cadence; answers questions appropriately. Neck: Supple. May also place a cool compress to area to ease pain. Click here for information on how to access and navigate iHuman. Ears: Canals patent. Eyes: PERRLA. Head is normocephalic, atraumatic and without lesions; hair evenly distributed. Complains fo generalized malaise. Normal penile shaft, without lesions or discharge. Healthy appearing adult female in no acute distress. The other symptoms include urethral discharge, dysuria, hematuria (Cash, 2014), Kidney Stone: Add Ct scan to determine the stone size, if the test of urine positive for renal calculi. Full ROM; no cervical lymphadenopathy; no occipital nodes. Cite all sources using APA format. You would not leave these in an official SOAP note. We also have a team of editors who read each paper from our writers just to make sure all papers are of HIGH QUALITY & PLAGIARISM FREE. Well estrogenized. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins. Pulses 3+ throughout. General Appearance: A healthy appearing adult male with acute distress. Epididymitis: fever, Swelling and tenderness of the scrotum (usually located on one side), patient may get relief with elevation of scrotum, which is positive Prehns sign. Provide a reference for your treatment plan (in APA format). Does your mother, father or siblings have any medical or psychiatric illnesses? Select your deadline and pay for your paper. EOMs intact. Ears: Canals patent. It is possible to have shingles flair up again in the future. Our writers are also well trained to follow client instructions as well adhere to various writing conventional writing structures as per the demand of specific articles. Hernia inguinal K40 (ICD-10 Code Lookup, 2016). https://digitalbookshelf.southuniversity.edu/#/books/9780826168757/, Nursing Capstone Project Writing Services, Nursing Annotated Bibliography by Professional, Online Nursing Research Paper writing service, Mean corpuscular hemoglobin concentration (MCHC). Capillary refill 2 seconds. Oral mucosa pink and moist. Posture erect. No extra sounds, clicks, rubs or murmurs. Posture erect. Prostrate is smooth, non-tender and free from nodules, is of normal size, sphincter tone is firm. Gastrointestinal: Abdomen flat; BS hyper active in all 4 quadrants. Maintains eye contact. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins. Skin is brown, warm, dry, clean and intact. Maintains eye contact. Baldwin was born in London, and studied chemistry at Imperial College London, where he also did a PhD. Describe the course of the patients illness, including when it began, character of symptoms, location where the symptoms began, aggravating or alleviating factors; pertinent positives and negatives, other related diseases, past illnesses, surgeries or past diagnostic testing related to present illness. It should be surgical intervention if patient get strangulated hernias (Cash, 2014). Speech is soft, though clear and of normal rate and cadence; answers questions appropriately. Clarify all the questions with customer support representatives and upload all the necessary files for the writer to use. Tetanus booster vaccine in 2010. Neck: Supple. Advanced assessment: Interpreting findings and formulating differential diagnoses. Abdomen soft, non-tender. Non-medication treatments: Maintain adequate hydratin b continuing to drink 68 glasses of water a day. Recommend smoking cessation patient not ready (Buttaro, Trybulski & Bailey, 2013). Quality isnt just an option, it is the only option. Chronic Illnesses/Major traumas:Patient has a significant history for hypertensionChronic Health Problems: Immunizations:Up to date on all immunizations. Clear to auscultation with no adventitous sounds bilaterally. Advanced assessment: Interpreting findings and formulating differential diagnoses. Neurological: Speech clear. Limit Tylenol to less than 4 g per day. Note: For purposes of this sample SOAP note comments on what is required for each section have been left in place. INT. We need some time to prepare a perfect essay for you. In writing, we will be precise and to the point and fill the paper with content as opposed to words aimed at beating the word count. Posture erect. Jack Baldwin VE iHuman Episodic SOAP Note and Differential Diagnoses Examples, Chief Complaint (CC): severe left groin pain for 6 hours. Safety status. Weight change, fatigue, fever, chills, night sweats, energy level, Chest pain, palpitations, PND, orthopnea, edema. All Rights Reserved Terms and Conditions Provide a reference for your treatment plan (in APA format). Ears: Canals patent. Well estrogenized. A manual of laboratory and diagnostic tests. Monitor for s/s of infection (increased redness, fever, pain, or purulent, fould smelling drainage). Bilateral TMs pearly grey with positive light reflex; landmarks easily visualized. The physical exam is significant for tachycardia, hypertension, diaphoresis, and severe pain in a swollen left groin. Musculoskeletal: Full ROM seen in all 4 extremities as patient moved about the exam room. It is also important to avoid people with weakened immune systems. Head is normocephalic, atraumatic and without lesions; hair evenly distributed. Deadline range from 6 hours to 30 days. Overwise, PRN. Right side normal. Monitor for s/s of infection (increased redness, fever, pain, or purulent, fould smelling drainage). Denies bruising or other abnormalities to skin, hair, or nails. Use this week's iHuman case titled "Jack Baldwin VE" and create a SOAP note with a treatment plan (located at the bottom of the SOAP note. You can protect your immune system with a healthy lifestyle, and keeping your stress at manageable levels can reduce your chances of getting shingles and other. Urgency, frequency burning, change in color of urine. Jack Baldwin VE iHuman Episodic SOAP Note and Differential Diagnoses Examples.
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