Soap Note 2 Chronic Conditions(Myastenia Gravis)

 

Soap Note 2 Chronic Conditions

Soap notes will be uploaded to Moodle and put through TURN-It-In (anti-Plagiarism program)

Late Assignment Policy

Assignments turned in late will have 1 point taken off for every day assignment is late, after 7 days assignment will get grade of 0. No exceptions

 Follow the MRU Soap Note Rubric as a guide:

Grading Rubric 

Student______________________________________

This sheet is to help you understand what we are looking for, and what our margin remarks might be about on your write ups of patients. Since at all of the white-ups that you hand in are uniform, this represents what MUST be included in every write-up.

1)      Identifying Data (___5pts): The opening list of the note. It contains age, sex, race, marital status, etc. The patient complaint should be given in quotes. If the patient has more than one complaint, each complaint should be listed separately (1, 2, etc.) and each addressed in the subjective and under the appropriate number.

2)      Subjective Data (___30pts.): This is the historical part of the note. It contains the following:

a) Symptom analysis/HPI(Location, quality , quantity or severity, timing, setting, factors that make it better or worse, and associate manifestations.(10pts).

b) Review of systems of associated systems, reporting all pertinent positives and negatives (10pts).

c) Any PMH, family hx, social hx, allergies, medications related to the complaint/problem (10pts). If more than one chief complaint, each should be written u in this manner.

3)      Objective Data(__25pt.): Vital signs need to be present. Height and Weight should be included where appropriate.

a)      Appropriate systems are examined, listed in the note and consistent with those identified in 2b.(10pts).

b)      Pertinent positives and negatives must be documented for each relevant system.

c)        Any abnormalities must be fully described. Measure and record sizes of things (likes moles, scars). Avoid using “ok”, “clear”, “within normal limits”, positive/ negative, and normal/abnormal to describe things. (5pts).

4)      Assessment (___10pts.): Diagnoses should be clearly listed and worded appropriately.

5)      Plan (___15pts.): Be sure to include any teaching, health maintenance and counseling along with the pharmacological and non-pharmacological measures. If you have more than one diagnosis, it is helpful to have this section divided into separate numbered sections.

6)      Subjective/ Objective, Assessment and Management and Consistent (___10pts.): Does the note support the appropriate differential diagnosis process? Is there evidence that you know what systems and what symptoms go with which complaints? The assessment/diagnoses should be consistent with the subjective section and then the assessment and plan. The management should be consistent with the assessment/ diagnoses identified.

7)      Clarity of the Write-up(___5pts.): Is it literate, organized and complete?

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Case 5 and 6(Knee Injury and Testicular Cancer )

 Knee Injury Case Studies A 15-year-old gymnast has noted knee pain that has become progressively worse during the past several months of intensive training for a statewide meet. Her physical examination indicated swelling in and around the left knee. She had some decreased range of motion and a clicking sound on flexion of the knee. The knee was otherwise stable. Studies Results Routine laboratory values Within normal limits (WNL) Long bone (femur, fibula, and tibia) X-ray No fracture Arthrocentesis with synovial fluid analysis Appearance Bloody (normal: clear and straw-colored) Mucin clot Good (normal: good) Fibrin clot Small (normal: none) White blood cells (WBCs) <200 WBC/mm3 (normal: <200 WBC/mm3 ) Neutrophils <25% (WNL) Glucose 100 mg/dL (normal: within 10 mg/dL of serum glucose level) Magnetic resonance imaging (MRI) of the knee Blood in the joint space. Tear in the posterior aspect of the medial meniscus. No cruciate or other ligament tears Arthroscopy Tear in posterior aspect of medial meniscus Diagnostic Analysis The radiographic studies of the long bones eliminated any possibility of fracture. Arthrocentesis indicated a bloody effusion, which was probably a result of trauma. The fibrin clot was further evidence of bleeding within the joint. Arthrography indicated a tear of the medial meniscus of the knee, a common injury for gymnasts. Arthroscopy corroborated that finding. Transarthroscopic medial meniscectomy was performed. Her postoperative course was uneventful. Critical Thinking Questions 1. One of the potential complications of arthroscopy is infection. What signs and symptoms of joint infection would you emphasize in your patient teaching? 2. Why is glucose evaluated in the synovial fluid analysis? 3. What are special tests used to differentiate type of Tendon tears in the knee ? Explain how they are performed (Always on boards)  

 Testicular Cancer Case Studies A 21-year-old male noted pain in his right testicle while studying hard for his midterm college examinations. On self-examination, he noted a “grape sized” mass in the right testicle. This finding was corroborated by his healthcare provider. This young man had a history of delayed descent of his right testicle until the age of 1 year old. Studies Results Routine laboratory studies Within normal limits (WNL) Ultrasound the testicle Solid mass, right testicle associated with calcifications HCG (human chorionic gonadotropin) 550mIU/mL (normal: <5) CT scan of the abdomen Enlarged retroperitoneal lymph nodes CT scan of the chest Multiple pulmonary nodules Diagnostic Analysis At semester break, this young man underwent right orchiectomy. Pathology was compatible with embryonal cell carcinoma. CT directed biopsy of the most prominent pulmonary nodule indicated embryonal cell carcinoma, compatible with metastatic testicular carcinoma. During a leave of absence from college, and after banking his sperm, this young man underwent aggressive chemotherapy. Repeat testing 12 weeks after chemotherapy showed complete resolution of the pulmonary nodules and enlarged retroperitoneal lymph nodes. Critical Thinking Questions 1. What impact did an undescended testicle have on this young man’s risk for developing testicular cancer? 2. What might be the side effects of cytotoxic chemotherapy? 3. What was the purpose of preserving his sperm before chemotherapy? 4. Is this young man’s age typical for the development of testicular carcinoma? 

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Nurse E-Portfolio for this course, you will be examining your perceptions of the nurse in the role of collecting and assessing information.

 

In this initial entry into your Nurse E-Portfolio for this course, you will be examining your perceptions of the nurse in the role of collecting and assessing information. Using the e-portfolio format, answer the following questions. Make sure you spend some time thinking about the answers to these questions before writing.

  1. What experiences have you had interviewing people to gather information?
  2. What communication skills do you have that will help you conduct interviews to gather information?
  3. What communication skills do you have that may hinder your ability to gather information? What can you do to overcome these?

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Nurse E-Portfolio for this course, you will be examining your perceptions of the nurse in the role of collecting and assessing information.

 

In this initial entry into your Nurse E-Portfolio for this course, you will be examining your perceptions of the nurse in the role of collecting and assessing information. Using the e-portfolio format, answer the following questions. Make sure you spend some time thinking about the answers to these questions before writing.

  1. What experiences have you had interviewing people to gather information?
  2. What communication skills do you have that will help you conduct interviews to gather information?
  3. What communication skills do you have that may hinder your ability to gather information? What can you do to overcome these?

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nutrition ESSAY

does a diet that’s high in carbohydrates or high in the wrong carbs, raise your risk  of diabetes?

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W 6-1

 When reviewing the literature and different types of evidence, there are often gaps in the findings. Are such gaps a help or a hindrance when wanting to create a change? At least 2 APA references. Thanks.

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Discussion Comments week 9

Comment using your own words but please provide at least one reference for each comment.

Do a half page for discussion #1 and another half page for discussion #2 for a total of one page.

Provide the comment for each discussion separate.

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NURSING ETHICS

 

Case Study on Moral Status

Based on “Case Study: Fetal Abnormality” and other required topic study materials, write a 750-1,000-word reflection that answers the following questions:

  1. What is the Christian view of the nature of human persons, and which theory of moral status is it compatible with? How is this related to the intrinsic human value and dignity?
  2. Which theory or theories are being used by Jessica, Marco, Maria, and Dr. Wilson to determine the moral status of the fetus? What from the case study specifically leads you to believe that they hold the theory you selected?
  3. How does the theory determine or influence each of their recommendations for action?
  4. What theory do you agree with? Why? How would that theory determine or influence the recommendation for action?

Remember to support your responses with the topic study materials.

While APA style is not required for the body of this assignment, solid academic writing is expected, and documentation of sources should be presented using APA formatting guidelines, which can be found in the APA Style Guide, located in the Student Success Center.

This assignment uses a rubric. Please review the rubric prior to beginning the assignment to become familiar with the expectations for successful completion.

You are required to submit this assignment to LopesWrite. Refer to the LopesWrite Technical Support articles for assistance.

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Cultural Diversity week 6 dis 2

 Pew Research findings show that education is the best predictor of a diverse social network. How do you think your education level impacts the diversity of your social network? 

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Cultural Diversity week 6 dis 2

 Pew Research findings show that education is the best predictor of a diverse social network. How do you think your education level impacts the diversity of your social network? 

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