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Home>Homework Answsers>Nursing homework help2 years ago14.08.20231Report issuefiles (1)nextsoap.pdfnextsoap.pdfEvalynn MDOB: 11/4/2019 Sex: F August/4/2023Encounter Type: Office VisitSUBJECTIVE:Chief Complaint:Patient is a 3-year-old female accompanied by parents presenting with intermittent cramping lasttime. No more cramping today. That improved. Also had pruritus of the buttocks. Thatimproved. No more pruritus. Used to having regular daily bowel movements. Daily regular BM.Denies recent fever, cough, runny nose, difficulty to breathing, diarrhea, vomiting or recentillness. Patient denies any history of previous adverse reaction to vaccines. Patient have noknown allergies to medications.Sick contact: dogs with pinwormSocial History:Smoking Status: Never SmokedOBJECTIVE:Vital Signs:Height: 104.50 cmWeight: 17.35 kgBMI: 15.89Blood Pressure: 105/61 mmHgTemperature: 36.50 CPulse: 105 beats/minResp. Rate: 24Physical Exam:Constitutional: Well developed. Well nourished. No acute distress.Neck: Full ROM, trachea midline positionNo thyromegalyRespiratory: Respiration non labored Good air entry No rales Clear to auscultation bilaterallyNo wheezingCardiovascular: No lifts, no heaves, or thrills No cyanosisS1S2 RRR (-) murmurNo murmurs, rubs, gallopsFemoral pulses symmetricalChest/Breasts: Symmetrical No nipple dischargeNo lumps, masses, or tendernessGastrointestinal (Abdomen): No masses or tenderness No herniasLiver and spleen non-tender, not enlargedGenitourinary: Female G/U: No external masses, lesions, scarsNo vulvar rashes or swellingLabia, clitoris, vaginal orifice, urethral meatus intact, without dischargeLymphatic: No cervical adenopathy(-) axillary adenopathyNo subclavian adenopathyNo epitrochlear adenopathy(-) occipital adenopathyMusculoskeletal: Digits are w/o clubbing or cyanosisEqual leg length No back deformitiesNo misalignment, defects, or deformitiesNo Scoliosis No muscle atrophy or weakness.Skin: Digits are w/o clubbing or cyanosisEqual leg length No back deformitiesNo misalignment, defects, or deformitiesNo Scoliosis No muscle atrophy or weakness.Neurological/Psychiatric: Normal tone Normal power Normal gaitASSESSMENT:Assessments:ICD-10 Assessments:3 year old girl for P/E.Appropriate G and DPLAN:Immunizations:Immunizations currently up to date.Care Plan:ANTICIPATORY GUIDANCENo barriers to learningSafety: Car seat, playground safety, sun exposure, falls, windows guards, pets, close supervision,passive smoke.Behavior: Praise good behaviors, handling undesirable behaviors (temper tantrums), need forindependence, sharing, exploration, provide choices, fantasy, fears, masturbation, imaginaryplaymates, enuresis.Other: Toilet training, brush teeth (no or little toothpaste), limit TV, reading (book types,repetition, point and name, turn pages, fill in words, reading signs and labels, have variety and letchildren choose).BARRIERS TO LEARNING: Age Culture ReligionLanguage Emotional Limited CognitionLimited Hearing Limited VisionReadiness to learn Yes NoLearning preferences:CBC PB PPDOther lab:Immunizations: (Check immunization card, document previous immunization, update ifnecessary) DTaP No. HIB / HBV No. Prevnar No.IPV No. FLU No. HBV No. HIB No. HAV No. MMR VZV PPD (if necessary) PentacelRTC: days wks mos. PRNPatient Instructions:F/U for September Flu shot. Encouraged to drink extra prune juice twice a day: morning andevening.Evalynn MPatient ID: 100294528 DOB: 11/4/2019 Sex: F Account No.:Encounter ID: 283756022 Encounter Date: 07/21/2023Encounter Type: Office VisitSUBJECTIVE:Chief Complaint:Patient is a 3 year old female accompanied by parents presenting with intermittent cramping10/10 abdominal pain x1 week, worsens at night. Also has pruritus of the buttocks. Parents reportseeing white dots on buttocks, possibly “eggs.” Reports constipation, has 3 bowel movements perweek. Used to have regular daily bowel movements. Tried olive oil, which helped at first but didnot end up resolving symptoms. Tried prune juice with no improvement. Has been eating less,small meals throughout the day.Denies recent fever, cough, runny nose, difficulty to breathing, diarrhea, vomiting or recentillness. Patient denies any history of previous adverse reaction to vaccines. Patient has no knownallergies to medications.Sick contact: dogs with pinwormHistory Of Present Illness:Diet: picky / balanced diet; 3 meals/day, has been eating lessSleep: 8 hours dailyElimination: Tvoids 3-4 times per day.Activity: Lives at home with mother, father, brother, and grandparernts. Attends daycare.Sick contacts: none reportedSocial History:Smoking Status: Never SmokedOBJECTIVE:Vital Signs:Height: 103.80 cmWeight: 16.45 kgBMI: 15.27Temperature: 36.90 CPulse: 88 beats/minResp. Rate: 22Head Circumference: 49.00Physical Exam:Constitutional: Well developed. Well nourished. No acute distress.Eye: red reflex present bilateral PERRLA Sclera white, conjunctive clear No strabismusEar: No scars, lesions, or masses Canal walls pink, without dischargeNose: Mucosa and turbinates pink Nares patentMouth: Gums pink Lips pink and symmetrical Oral mucosa pink / moist No cleft palateTongue moist, no ulcersNeck: Full ROM, trachea midline positionNo thyromegalyRespiratory: Respiration non labored Good air entry No rales Clear to auscultation bilaterallyNo wheezingCardiovascular: No lifts, no heaves, or thrills No cyanosisS1S2 RRR (-) murmurNo murmurs, rubs, gallopsFemoral pulses symmetricalChest/Breasts: Symmetrical No nipple dischargeNo lumps, masses, or tendernessGastrointestinal (Abdomen): No masses or tenderness No herniasLiver and spleen non-tender, not enlargedGenitourinary: Female G/U: No external masses, lesions, scarsNo vulvar rashes or swellingLabia, clitoris, vaginal orifice, urethral meatus intact, without dischargeLymphatic: No cervical adenopathy(-) axillary adenopathyNo subclavian adenopathyNo epitrochlear adenopathy(-) occipital adenopathyMusculoskeletal: Digits are w/o clubbing or cyanosisEqual leg length No back deformitiesNo misalignment, defects, or deformitiesNo Scoliosis No muscle atrophy or weakness.Skin: Digits are w/o clubbing or cyanosisEqual leg length No back deformitiesNo misalignment, defects, or deformitiesNo Scoliosis No muscle atrophy or weakness.Neurological/Psychiatric: Normal tone Normal power Normal gaitASSESSMENT:Diagnosis:ICD-10 Codes:1)B80; Enterobiasis2)L290; Pruritus ani3)R1084; Generalized abdominal pain4)K5901; Slow transit constipationAssessments:ICD-10 Assessments:3 year old girl for P/E.Appropriate G and DPLAN:Procedures:1) 99214; Office Visit Established Mod-High 25 minMedications:Mebendazole Powder; Take 1 tablet (100mg) and chew x 1; Qty: 1; Refills: 0Immunizations:Immunizations currently up to date.Care Plan:ANTICIPATORY GUIDANCENo barriers to learningSafety: Car seat, playground safety, sun exposure, falls, windows guards, pets, close supervision,passive smoke.Behavior: Praise good behaviors, handling undesirable behaviors (temper tantrums), need forindependence, sharing, exploration, provide choices, fantasy, fears, masturbation, imaginaryplaymates, enuresis.Other: Toilet training, brush teeth (no or little toothpaste), limit TV, reading (book types,repetition, point and name, turn pages, fill in words, reading signs and labels, have variety and letchildren choose).BARRIERS TO LEARNING: Age Culture ReligionLanguage Emotional Limited CognitionLimited Hearing Limited VisionReadiness to learn Yes NoLearning preferences:CBC PB PPDOther lab:Immunizations: (Check immunization card, document previous immunization, update ifnecessary) DTaP No. HIB / HBV No. Prevnar No.IPV No. FLU No. HBV No. HIB No. HAV No. MMR VZV PPD (if necessary) PentacelRTC: days wks mos. PRNPatient Instructions:- discuss about differential diagnosis of abdominal pain: constipation with diarrhea presentationor hard stool,- pinworm for itching perineal at night- discuss that the diagnosis is based on identifying pinworm during night with scotch tape;and discuss how to do it- risk/benefits/alternative discuss about just treating it- Constipation- will give 3 days of pedialax at night in a row to clear possible diagnosis of constipation- follow up in 2 weeks; may need another dose of mebendazole 100 mg/weekThis is for next week problem soap note. Use the same template. (You can take your time)3yrs old girl came twice to Doctor office. First time July. Second time Aug.The reason was abdominal pain and constipation, pruritus(mom believed the abdominal pain is causedby pinworm at that time by touching their dog))However now all solved happily. You can modify the story.nextsoap.pdfEvalynn MDOB: 11/4/2019 Sex: F August/4/2023Encounter Type: Office VisitSUBJECTIVE:Chief Complaint:Patient is a 3-year-old female accompanied by parents presenting with intermittent cramping lasttime. No more cramping today. That improved. Also had pruritus of the buttocks. Thatimproved. No more pruritus. Used to having regular daily bowel movements. Daily regular BM.Denies recent fever, cough, runny nose, difficulty to breathing, diarrhea, vomiting or recentillness. Patient denies any history of previous adverse reaction to vaccines. Patient have noknown allergies to medications.Sick contact: dogs with pinwormSocial History:Smoking Status: Never SmokedOBJECTIVE:Vital Signs:Height: 104.50 cmWeight: 17.35 kgBMI: 15.89Blood Pressure: 105/61 mmHgTemperature: 36.50 CPulse: 105 beats/minResp. Rate: 24Physical Exam:Constitutional: Well developed. Well nourished. No acute distress.Neck: Full ROM, trachea midline positionNo thyromegalyRespiratory: Respiration non labored Good air entry No rales Clear to auscultation bilaterallyNo wheezingCardiovascular: No lifts, no heaves, or thrills No cyanosisS1S2 RRR (-) murmurNo murmurs, rubs, gallopsFemoral pulses symmetricalChest/Breasts: Symmetrical No nipple dischargeNo lumps, masses, or tendernessGastrointestinal (Abdomen): No masses or tenderness No herniasLiver and spleen non-tender, not enlargedGenitourinary: Female G/U: No external masses, lesions, scarsNo vulvar rashes or swellingLabia, clitoris, vaginal orifice, urethral meatus intact, without dischargeLymphatic: No cervical adenopathy(-) axillary adenopathyNo subclavian adenopathyNo epitrochlear adenopathy(-) occipital adenopathyMusculoskeletal: Digits are w/o clubbing or cyanosisEqual leg length No back deformitiesNo misalignment, defects, or deformitiesNo Scoliosis No muscle atrophy or weakness.Skin: Digits are w/o clubbing or cyanosisEqual leg length No back deformitiesNo misalignment, defects, or deformitiesNo Scoliosis No muscle atrophy or weakness.Neurological/Psychiatric: Normal tone Normal power Normal gaitASSESSMENT:Assessments:ICD-10 Assessments:3 year old girl for P/E.Appropriate G and DPLAN:Immunizations:Immunizations currently up to date.Care Plan:ANTICIPATORY GUIDANCENo barriers to learningSafety: Car seat, playground safety, sun exposure, falls, windows guards, pets, close supervision,passive smoke.Behavior: Praise good behaviors, handling undesirable behaviors (temper tantrums), need forindependence, sharing, exploration, provide choices, fantasy, fears, masturbation, imaginaryplaymates, enuresis.Other: Toilet training, brush teeth (no or little toothpaste), limit TV, reading (book types,repetition, point and name, turn pages, fill in words, reading signs and labels, have variety and letchildren choose).BARRIERS TO LEARNING: Age Culture ReligionLanguage Emotional Limited CognitionLimited Hearing Limited VisionReadiness to learn Yes NoLearning preferences:CBC PB PPDOther lab:Immunizations: (Check immunization card, document previous immunization, update ifnecessary) DTaP No. HIB / HBV No. Prevnar No.IPV No. FLU No. HBV No. HIB No. HAV No. MMR VZV PPD (if necessary) PentacelRTC: days wks mos. PRNPatient Instructions:F/U for September Flu shot. Encouraged to drink extra prune juice twice a day: morning andevening.Evalynn MPatient ID: 100294528 DOB: 11/4/2019 Sex: F Account No.:Encounter ID: 283756022 Encounter Date: 07/21/2023Encounter Type: Office VisitSUBJECTIVE:Chief Complaint:Patient is a 3 year old female accompanied by parents presenting with intermittent cramping10/10 abdominal pain x1 week, worsens at night. Also has pruritus of the buttocks. Parents reportseeing white dots on buttocks, possibly “eggs.” Reports constipation, has 3 bowel movements perweek. Used to have regular daily bowel movements. Tried olive oil, which helped at first but didnot end up resolving symptoms. Tried prune juice with no improvement. Has been eating less,small meals throughout the day.Denies recent fever, cough, runny nose, difficulty to breathing, diarrhea, vomiting or recentillness. Patient denies any history of previous adverse reaction to vaccines. Patient has no knownallergies to medications.Sick contact: dogs with pinwormHistory Of Present Illness:Diet: picky / balanced diet; 3 meals/day, has been eating lessSleep: 8 hours dailyElimination: Tvoids 3-4 times per day.Activity: Lives at home with mother, father, brother, and grandparernts. Attends daycare.Sick contacts: none reportedSocial History:Smoking Status: Never SmokedOBJECTIVE:Vital Signs:Height: 103.80 cmWeight: 16.45 kgBMI: 15.27Temperature: 36.90 CPulse: 88 beats/minResp. Rate: 22Head Circumference: 49.00Physical Exam:Constitutional: Well developed. Well nourished. No acute distress.Eye: red reflex present bilateral PERRLA Sclera white, conjunctive clear No strabismusEar: No scars, lesions, or masses Canal walls pink, without dischargeNose: Mucosa and turbinates pink Nares patentMouth: Gums pink Lips pink and symmetrical Oral mucosa pink / moist No cleft palateTongue moist, no ulcersNeck: Full ROM, trachea midline positionNo thyromegalyRespiratory: Respiration non labored Good air entry No rales Clear to auscultation bilaterallyNo wheezingCardiovascular: No lifts, no heaves, or thrills No cyanosisS1S2 RRR (-) murmurNo murmurs, rubs, gallopsFemoral pulses symmetricalChest/Breasts: Symmetrical No nipple dischargeNo lumps, masses, or tendernessGastrointestinal (Abdomen): No masses or tenderness No herniasLiver and spleen non-tender, not enlargedGenitourinary: Female G/U: No external masses, lesions, scarsNo vulvar rashes or swellingLabia, clitoris, vaginal orifice, urethral meatus intact, without dischargeLymphatic: No cervical adenopathy(-) axillary adenopathyNo subclavian adenopathyNo epitrochlear adenopathy(-) occipital adenopathyMusculoskeletal: Digits are w/o clubbing or cyanosisEqual leg length No back deformitiesNo misalignment, defects, or deformitiesNo Scoliosis No muscle atrophy or weakness.Skin: Digits are w/o clubbing or cyanosisEqual leg length No back deformitiesNo misalignment, defects, or deformitiesNo Scoliosis No muscle atrophy or weakness.Neurological/Psychiatric: Normal tone Normal power Normal gaitASSESSMENT:Diagnosis:ICD-10 Codes:1)B80; Enterobiasis2)L290; Pruritus ani3)R1084; Generalized abdominal pain4)K5901; Slow transit constipationAssessments:ICD-10 Assessments:3 year old girl for P/E.Appropriate G and DPLAN:Procedures:1) 99214; Office Visit Established Mod-High 25 minMedications:Mebendazole Powder; Take 1 tablet (100mg) and chew x 1; Qty: 1; Refills: 0Immunizations:Immunizations currently up to date.Care Plan:ANTICIPATORY GUIDANCENo barriers to learningSafety: Car seat, playground safety, sun exposure, falls, windows guards, pets, close supervision,passive smoke.Behavior: Praise good behaviors, handling undesirable behaviors (temper tantrums), need forindependence, sharing, exploration, provide choices, fantasy, fears, masturbation, imaginaryplaymates, enuresis.Other: Toilet training, brush teeth (no or little toothpaste), limit TV, reading (book types,repetition, point and name, turn pages, fill in words, reading signs and labels, have variety and letchildren choose).BARRIERS TO LEARNING: Age Culture ReligionLanguage Emotional Limited CognitionLimited Hearing Limited VisionReadiness to learn Yes NoLearning preferences:CBC PB PPDOther lab:Immunizations: (Check immunization card, document previous immunization, update ifnecessary) DTaP No. HIB / HBV No. Prevnar No.IPV No. FLU No. HBV No. HIB No. HAV No. MMR VZV PPD (if necessary) PentacelRTC: days wks mos. PRNPatient Instructions:- discuss about differential diagnosis of abdominal pain: constipation with diarrhea presentationor hard stool,- pinworm for itching perineal at night- discuss that the diagnosis is based on identifying pinworm during night with scotch tape;and discuss how to do it- risk/benefits/alternative discuss about just treating it- Constipation- will give 3 days of pedialax at night in a row to clear possible diagnosis of constipation- follow up in 2 weeks; may need another dose of mebendazole 100 mg/weekThis is for next week problem soap note. Use the same template. (You can take your time)3yrs old girl came twice to Doctor office. First time July. Second time Aug.The reason was abdominal pain and constipation, pruritus(mom believed the abdominal pain is causedby pinworm at that time by touching their dog))However now all solved happily. You can modify the story.Bids(52)Jahky BPROF_ALISTERMUSYOKIONES A+Dr CloverTeacher A+ WorkSheryl HoganDemi_RoseFiona DavaBrilliant GeekAshley EllieProf Double RTopanswersPremiumsherry proffAmerican TutorPROFESSOR DAISYJudithTutorProf Nato(PhD)Quality AssignmentsDr. BeneveShow All Bidsother Questions(10)lab3ORG-812 Module 7 DQ 2RES-850 Module 4 DQ 1global human resourcesNeed help ASAP plz!!!Unit VII EssayInformation Systems/ComputerNursing Quantitative MatrixUnit VI Discussion Question Risk ManagementPaper

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