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Home>Homework Answsers>Nursing homework helpnursing researchnursingMMa year ago05.03.202410Report issuefiles (3)NU610Unit1CaseStudy-draftrevision4_28_221.docxSOAPNoteTemplate-Final3.docxarchive10.zipNU610Unit1CaseStudy-draftrevision4_28_221.docxNU610 Unit 1 Case StudyA 50-year-old man comes to your office for a routine physical examination. He is a new patient to your practice. He states his father died at the age of 73 of a heart attack. His mother is alive at the age of 80. He has hypertension, which he takes chlorthalidone 25 mg PO daily. Takes Tylenol as needed for pain. Denies seasonal or drug allergies. He has two younger siblings with no known chronic medical conditions. Last eye and dental exam two years ago. He is married in a monogamous relationship without children. Has a high school diploma. Works full-time for local landscaping business. He does not smoke, drink alcohol, use any recreational drugs and does not exercise. He denies fever, chills, weight loss or weight gain. He denies hearing changes, headaches or dizziness. He reports some visual changes when reading close-up. He denies shortness of breath, dyspnea on exertion, swelling or chest pain. He reports increase urination and thirst. Denies abdominal pain, nausea, vomiting or changes in appetite. He reports daily BM. Denies rashes or bug bites. Uses sunscreen daily due to working outside. Denies anxiety or depression. On examination his blood pressure is 126/82, pulse is 80 beats/min, respiratory rate is 18. Height is 67 inches and weight is 190lbs. Does not appear in acute distress, responses are appropriate and appears reliable source. Alert, oriented to person, place, time and situation. Well-nourished, skin warm, dry and intact. Normocephalic. Pupils size 3 mm, equal and reactive to light. Extraocular eye movements intact to six directions. Tympanic membranes gray with adequate cone of light bilaterally. Mucous membranes pink and moist. No palpable masses, thyromegaly, lymphadenopathy or JVD. Regular heart rate and rhythm, S1 and S2. No bruits auscultated. Capillary refill less than 3 seconds. Breath sounds clear bilaterally to auscultation. No use of accessory muscles or purse lip-breathing. Soft, non-tender, non-distended, normoactive bowel sound. No organomegaly or guarding. Denies numbness or tingling. He reports he has not had HIV or PSA screenings.SOAPNoteTemplate-Final3.docxSOAP Note _______NU___:_________Herzing UniversityName:_________________________Typhon Encounter #: _____________________Comprehensive:____Focused:____S: SUBJECTIVE DATACC:What are they being seen for? This is the reason that the patient sought care, stated in their own words/words of their caregiver, or paraphrased.HPI:Use the “OLDCART” approach for collecting data and documenting findings. [O=onset, L=location, D=duration, C=characteristics, A=associated/aggravating factors, R=relieving factors, T=treatment, S=summary]PMH:This should include past illness/diagnosis, conditions, traumas, hospitalizations, and surgical history. Include dates if possible.ALLERGIESState the offending medication/food and the reactions.MEDICATIONSNames, dosages, and routes of administration along with indication of use.SHRelated to the problem, educational level/literacy, smoking, alcohol, drugs, HIV risk, sexually active, caffeine, work and other stressors. Cultural and spiritual beliefs that impact health and illness. Financial resources.FHUse terms like maternal, paternal, and the diseases along with the ages they were deceased or diagnosed if known.HEALTH PROMOTION & MAINTENANCERequired for all SOAP notes:Immunizations, exercise, diet, etc. Remember to use theUnited States Clinical Preventative Services Task Force (USPSTF)for age-appropriate indicators. This should reflect what the patient is presently doing regarding the guidelines. Other wellness visits including but not limited to dental and eye exams.ROS(put N/A in sections not completed day of exam)ConstitutionalHeadEyesEars, Nose, Mouth, ThroatNeckCardiovascular/Peripheral VascularRespiratoryBreastGastrointestinalGenitourinaryMusculoskeletalIntegumentaryNeurologicalPsychiatric (screening tools: Ex: PHQ-9, MMSE, GAD-7)EndocrineHematologic/LymphaticAllergic/ImmunologicOtherO: OBJECTIVE DATAVITALS:HR:RR:BP:Temp:SpO2%:Ht:Wt:BMI:Age:LMP:PAIN:PHYSICAL EXAM(Pertinent data related to presenting problem or visit type. Put N/A in sections not completed day of exam)General AppearanceHeadEyesENT, MouthNeckCardiovascular/Peripheral VascularRespiratoryBreastGastrointestinalGenitourinary Male· External Exam· Internal ExamGenitourinary Female· External Exam· Internal ExamMusculoskeletalIntegumentaryNeurologicalPsychiatricEndocrineHematologic/LymphaticAllergic/ImmunologicOtherA: ASSESSMENT AND DIAGNOSISDIAGNOSISICD-10 CODESPRIORITIZE DIAGNOSIS1.2.3.VISIT CODESCPT BILLING CODESDIAGNOSTICSPOC TESTINGTESTS REVIEWEDP: PLANACTIONS1.Diagnosis:Diagnostics Order: labs, diagnostics testing (tests that you planned for/ordered during the encounter that you plan to review/evaluate relative to your work up for the patient’s chief complaint.)Therapeutic: changes in meds, skin care, counseling, include full prescribing information for any pharmacologic interventions including quantity and number of refills for any new or refilled medications. (Ex: Amoxicillin 500mg, PO, q12h, x 7 days, #14, no refills)Education: information clients need in order to address their health problems. Include follow-up care. Anticipatory guidance and counseling.Consultation/Collaboration: referrals or consult while in clinic with another provider. If no referral made was there a possible referral you could make and why? Advance care planning.2.Diagnosis:Diagnostics Order:Therapeutic:Education:Consultation/Collaboration:3.Diagnosis:Diagnostics Order:Therapeutic:Education:Consultation/Collaboration:PREVENTITIVE(Used for comprehensive exams)Enter Guidance, Health Promotion, and/or Disease Prevention for patient, family, and/or caregiver.FOLLOW UParchive10.zipThis file is too large to display.View in new windowarchive10.zipThis file is too large to display.View in new windowNU610Unit1CaseStudy-draftrevision4_28_221.docxNU610 Unit 1 Case StudyA 50-year-old man comes to your office for a routine physical examination. He is a new patient to your practice. He states his father died at the age of 73 of a heart attack. His mother is alive at the age of 80. He has hypertension, which he takes chlorthalidone 25 mg PO daily. Takes Tylenol as needed for pain. Denies seasonal or drug allergies. He has two younger siblings with no known chronic medical conditions. Last eye and dental exam two years ago. He is married in a monogamous relationship without children. Has a high school diploma. Works full-time for local landscaping business. He does not smoke, drink alcohol, use any recreational drugs and does not exercise. He denies fever, chills, weight loss or weight gain. He denies hearing changes, headaches or dizziness. He reports some visual changes when reading close-up. He denies shortness of breath, dyspnea on exertion, swelling or chest pain. He reports increase urination and thirst. Denies abdominal pain, nausea, vomiting or changes in appetite. He reports daily BM. Denies rashes or bug bites. Uses sunscreen daily due to working outside. Denies anxiety or depression. On examination his blood pressure is 126/82, pulse is 80 beats/min, respiratory rate is 18. Height is 67 inches and weight is 190lbs. Does not appear in acute distress, responses are appropriate and appears reliable source. Alert, oriented to person, place, time and situation. Well-nourished, skin warm, dry and intact. Normocephalic. Pupils size 3 mm, equal and reactive to light. Extraocular eye movements intact to six directions. Tympanic membranes gray with adequate cone of light bilaterally. Mucous membranes pink and moist. No palpable masses, thyromegaly, lymphadenopathy or JVD. Regular heart rate and rhythm, S1 and S2. No bruits auscultated. Capillary refill less than 3 seconds. Breath sounds clear bilaterally to auscultation. No use of accessory muscles or purse lip-breathing. Soft, non-tender, non-distended, normoactive bowel sound. No organomegaly or guarding. Denies numbness or tingling. He reports he has not had HIV or PSA screenings.SOAPNoteTemplate-Final3.docxSOAP Note _______NU___:_________Herzing UniversityName:_________________________Typhon Encounter #: _____________________Comprehensive:____Focused:____S: SUBJECTIVE DATACC:What are they being seen for? This is the reason that the patient sought care, stated in their own words/words of their caregiver, or paraphrased.HPI:Use the “OLDCART” approach for collecting data and documenting findings. [O=onset, L=location, D=duration, C=characteristics, A=associated/aggravating factors, R=relieving factors, T=treatment, S=summary]PMH:This should include past illness/diagnosis, conditions, traumas, hospitalizations, and surgical history. Include dates if possible.ALLERGIESState the offending medication/food and the reactions.MEDICATIONSNames, dosages, and routes of administration along with indication of use.SHRelated to the problem, educational level/literacy, smoking, alcohol, drugs, HIV risk, sexually active, caffeine, work and other stressors. Cultural and spiritual beliefs that impact health and illness. Financial resources.FHUse terms like maternal, paternal, and the diseases along with the ages they were deceased or diagnosed if known.HEALTH PROMOTION & MAINTENANCERequired for all SOAP notes:Immunizations, exercise, diet, etc. Remember to use theUnited States Clinical Preventative Services Task Force (USPSTF)for age-appropriate indicators. This should reflect what the patient is presently doing regarding the guidelines. Other wellness visits including but not limited to dental and eye exams.ROS(put N/A in sections not completed day of exam)ConstitutionalHeadEyesEars, Nose, Mouth, ThroatNeckCardiovascular/Peripheral VascularRespiratoryBreastGastrointestinalGenitourinaryMusculoskeletalIntegumentaryNeurologicalPsychiatric (screening tools: Ex: PHQ-9, MMSE, GAD-7)EndocrineHematologic/LymphaticAllergic/ImmunologicOtherO: OBJECTIVE DATAVITALS:HR:RR:BP:Temp:SpO2%:Ht:Wt:BMI:Age:LMP:PAIN:PHYSICAL EXAM(Pertinent data related to presenting problem or visit type. Put N/A in sections not completed day of exam)General AppearanceHeadEyesENT, MouthNeckCardiovascular/Peripheral VascularRespiratoryBreastGastrointestinalGenitourinary Male· External Exam· Internal ExamGenitourinary Female· External Exam· Internal ExamMusculoskeletalIntegumentaryNeurologicalPsychiatricEndocrineHematologic/LymphaticAllergic/ImmunologicOtherA: ASSESSMENT AND DIAGNOSISDIAGNOSISICD-10 CODESPRIORITIZE DIAGNOSIS1.2.3.VISIT CODESCPT BILLING CODESDIAGNOSTICSPOC TESTINGTESTS REVIEWEDP: PLANACTIONS1.Diagnosis:Diagnostics Order: labs, diagnostics testing (tests that you planned for/ordered during the encounter that you plan to review/evaluate relative to your work up for the patient’s chief complaint.)Therapeutic: changes in meds, skin care, counseling, include full prescribing information for any pharmacologic interventions including quantity and number of refills for any new or refilled medications. (Ex: Amoxicillin 500mg, PO, q12h, x 7 days, #14, no refills)Education: information clients need in order to address their health problems. Include follow-up care. Anticipatory guidance and counseling.Consultation/Collaboration: referrals or consult while in clinic with another provider. If no referral made was there a possible referral you could make and why? Advance care planning.2.Diagnosis:Diagnostics Order:Therapeutic:Education:Consultation/Collaboration:3.Diagnosis:Diagnostics Order:Therapeutic:Education:Consultation/Collaboration:PREVENTITIVE(Used for comprehensive exams)Enter Guidance, Health Promotion, and/or Disease Prevention for patient, family, and/or caregiver.FOLLOW UParchive10.zipThis file is too large to display.View in new windowNU610Unit1CaseStudy-draftrevision4_28_221.docxNU610 Unit 1 Case StudyA 50-year-old man comes to your office for a routine physical examination. He is a new patient to your practice. He states his father died at the age of 73 of a heart attack. His mother is alive at the age of 80. He has hypertension, which he takes chlorthalidone 25 mg PO daily. Takes Tylenol as needed for pain. Denies seasonal or drug allergies. He has two younger siblings with no known chronic medical conditions. Last eye and dental exam two years ago. He is married in a monogamous relationship without children. Has a high school diploma. Works full-time for local landscaping business. He does not smoke, drink alcohol, use any recreational drugs and does not exercise. He denies fever, chills, weight loss or weight gain. He denies hearing changes, headaches or dizziness. He reports some visual changes when reading close-up. He denies shortness of breath, dyspnea on exertion, swelling or chest pain. He reports increase urination and thirst. Denies abdominal pain, nausea, vomiting or changes in appetite. He reports daily BM. Denies rashes or bug bites. Uses sunscreen daily due to working outside. Denies anxiety or depression. On examination his blood pressure is 126/82, pulse is 80 beats/min, respiratory rate is 18. Height is 67 inches and weight is 190lbs. Does not appear in acute distress, responses are appropriate and appears reliable source. Alert, oriented to person, place, time and situation. Well-nourished, skin warm, dry and intact. Normocephalic. Pupils size 3 mm, equal and reactive to light. Extraocular eye movements intact to six directions. Tympanic membranes gray with adequate cone of light bilaterally. Mucous membranes pink and moist. No palpable masses, thyromegaly, lymphadenopathy or JVD. Regular heart rate and rhythm, S1 and S2. No bruits auscultated. Capillary refill less than 3 seconds. Breath sounds clear bilaterally to auscultation. No use of accessory muscles or purse lip-breathing. Soft, non-tender, non-distended, normoactive bowel sound. No organomegaly or guarding. Denies numbness or tingling. He reports he has not had HIV or PSA screenings.SOAPNoteTemplate-Final3.docxSOAP Note _______NU___:_________Herzing UniversityName:_________________________Typhon Encounter #: _____________________Comprehensive:____Focused:____S: SUBJECTIVE DATACC:What are they being seen for? This is the reason that the patient sought care, stated in their own words/words of their caregiver, or paraphrased.HPI:Use the “OLDCART” approach for collecting data and documenting findings. [O=onset, L=location, D=duration, C=characteristics, A=associated/aggravating factors, R=relieving factors, T=treatment, S=summary]PMH:This should include past illness/diagnosis, conditions, traumas, hospitalizations, and surgical history. Include dates if possible.ALLERGIESState the offending medication/food and the reactions.MEDICATIONSNames, dosages, and routes of administration along with indication of use.SHRelated to the problem, educational level/literacy, smoking, alcohol, drugs, HIV risk, sexually active, caffeine, work and other stressors. Cultural and spiritual beliefs that impact health and illness. Financial resources.FHUse terms like maternal, paternal, and the diseases along with the ages they were deceased or diagnosed if known.HEALTH PROMOTION & MAINTENANCERequired for all SOAP notes:Immunizations, exercise, diet, etc. Remember to use theUnited States Clinical Preventative Services Task Force (USPSTF)for age-appropriate indicators. This should reflect what the patient is presently doing regarding the guidelines. Other wellness visits including but not limited to dental and eye exams.ROS(put N/A in sections not completed day of exam)ConstitutionalHeadEyesEars, Nose, Mouth, ThroatNeckCardiovascular/Peripheral VascularRespiratoryBreastGastrointestinalGenitourinaryMusculoskeletalIntegumentaryNeurologicalPsychiatric (screening tools: Ex: PHQ-9, MMSE, GAD-7)EndocrineHematologic/LymphaticAllergic/ImmunologicOtherO: OBJECTIVE DATAVITALS:HR:RR:BP:Temp:SpO2%:Ht:Wt:BMI:Age:LMP:PAIN:PHYSICAL EXAM(Pertinent data related to presenting problem or visit type. Put N/A in sections not completed day of exam)General AppearanceHeadEyesENT, MouthNeckCardiovascular/Peripheral VascularRespiratoryBreastGastrointestinalGenitourinary Male· External Exam· Internal ExamGenitourinary Female· External Exam· Internal ExamMusculoskeletalIntegumentaryNeurologicalPsychiatricEndocrineHematologic/LymphaticAllergic/ImmunologicOtherA: ASSESSMENT AND DIAGNOSISDIAGNOSISICD-10 CODESPRIORITIZE DIAGNOSIS1.2.3.VISIT CODESCPT BILLING CODESDIAGNOSTICSPOC TESTINGTESTS REVIEWEDP: PLANACTIONS1.Diagnosis:Diagnostics Order: labs, diagnostics testing (tests that you planned for/ordered during the encounter that you plan to review/evaluate relative to your work up for the patient’s chief complaint.)Therapeutic: changes in meds, skin care, counseling, include full prescribing information for any pharmacologic interventions including quantity and number of refills for any new or refilled medications. (Ex: Amoxicillin 500mg, PO, q12h, x 7 days, #14, no refills)Education: information clients need in order to address their health problems. Include follow-up care. Anticipatory guidance and counseling.Consultation/Collaboration: referrals or consult while in clinic with another provider. If no referral made was there a possible referral you could make and why? Advance care planning.2.Diagnosis:Diagnostics Order:Therapeutic:Education:Consultation/Collaboration:3.Diagnosis:Diagnostics Order:Therapeutic:Education:Consultation/Collaboration:PREVENTITIVE(Used for comprehensive exams)Enter Guidance, Health Promotion, and/or Disease Prevention for patient, family, and/or caregiver.FOLLOW UParchive10.zipThis file is too large to display.View in new window123Bids(55)Miss DeannaDr. Ellen RMPROF_ALISTERSheryl HoganProf Double REmily Clarefirstclass tutorDoctor.NamiraFiona DavaDr CloverMISS HILLARY A+Discount AssigngrA+de plusJahky BProWritingGuruDr. Everleigh_JKIsabella HarvardBrilliant GeekTutor Cyrus KenAshley EllieShow All Bidsother Questions(10)Short paperFundamentals of small group communication myers andersonassistance with bold printLife Span MWVolcanic eruptions add carbon dioxide to the atmosphere. 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