SOAP Exemplar

Comprehensive SOAP Exemplar

Comprehensive SOAP Exemplar

Purpose: To demonstrate what each section of the SOAP note should include. Remember that Nurse Practitioners treat patients in a holistic manner and your SOAP note should reflect that premise.

Patient Initials: _______ Age: _______ Gender: _______

SUBJECTIVE DATA:

Chief Complaint (CC): Coughing up phlegm and fever

History of Present Illness (HPI): Sara Jones is a 65 year old Caucasian female who presents today with a productive cough x 3 weeks and fever for the last three days. She reported that the “cold feels like it is descending into her chest”. The cough is nagging and productive. She brought in a few paper towels with expectorated phlegm – yellow/brown in color. She has associated symptoms of dyspnea of exertion and fever. Her Tmax was reported to be 102.4, last night. She has been taking Ibuprofen 400mg about every 6 hours and the fever breaks, but returns after the medication wears off. She rated the severity of her symptom discomfort at 4/10.

Medications:

1.) Lisinopril 10mg daily

2.) Combivent 2 puffs every 6 hours as needed

3.) Serovent daily

4.) Salmeterol daily

5.) Over the counter Ibuprofen 200mg -2 PO as needed

6.) Over the counter Benefiber

7.) Flonase 1 spray each night as needed for allergic rhinitis symptoms

Allergies:

Sulfa drugs – rash

Past Medical History (PMH):

1.) Emphysema with recent exacerbation 1 month ago – deferred admission – RX’d with outpatient antibiotics and an hand held nebulizer treatments.

2.) Hypertension – well controlled

3.) Gastroesophageal reflux (GERD) – quiet on no medication

4.) Osteopenia

5.) Allergic rhinitis

Past Surgical History (PSH):

1.) Cholecystectomy 1994

2.) Total abdominal hysterectomy (TAH) 1998

Sexual/Reproductive History:

Heterosexual

G1P1A0

Non-menstrating – TAH 1998

Personal/Social History:

She has smoked 2 packs of cigarettes daily x 30 years; denied ETOH or illicit drug use.

Immunization History:

Her immunizations are up to date. She received the influenza vaccine last November and the Pneumococcal vaccine at the same time.

Significant Family History:

Two brothers – one with diabetes, dx at age 65 and the other with prostate CA, dx at age 62. She has 1 daughter, in her 50’s, healthy, living in nearby neighborhood.

Lifestyle:

She is a retired; widowed x 8 years; lives in the city, moderate crime area, with good public transportation. She college graduate, owns her home and receives a pension of $50,000 annually – financially stable.

She has a primary care nurse practitioner provider and goes for annual and routine care twice annually and as needed for episodic care. She has medical insurance but often asks for drug samples for cost savings. She has a healthy diet and eating pattern. There are resources and community groups in her area at the senior center and she attends regularly. She enjoys bingo. She has a good support system composed of family and friends.

Review of Systems:

General: + fatigue since the illness started; + fever, no chills or night sweats; no recent weight gains of losses of significance.

HEENT: no changes in vision or hearing; she does wear glasses and her last eye exam was 1 ½ years ago. She reported no history of glaucoma, diplopia, floaters, excessive tearing or photophobia. She does have bilateral small cataracts that are being followed by her ophthalmologist. She has had no recent ear infections, tinnitus, or discharge from the ears. She reported her sense of smell is intact. She has not had any episodes of epistaxis. She does not have a history of nasal polyps or recent sinus infection. She has history of allergic rhinitis that is seasonal. Her last dental exam was 3/2014. She denied ulceration, lesions, gingivitis, gum bleeding, and has no dental appliances. She has had no difficulty chewing or swallowing.

Neck: no pain, injury, or history of disc disease or compression. Her last Bone Mineral density (BMD) test was 2013 and showed mild osteopenia, she said.

Breasts: No reports of breast changes. No history of lesions, masses or rashes. No history of abnormal mammograms.

Repiratory: + cough and sputum production (see HPI); denied hemoptysis, no difficulty breathing at rest; + dyspnea on exertion; she has history of COPD and community acquired pneumonia 2012. Last PPD was 2013. Last CXR – 1 month ago.

CV: no chest discomfort, palpitations, history of murmur; no history of arrhythmias, orthopnea, paroxysmal nocturnal dyspnea, edema, or claudication. Date of last ECG/cardiac work up is unknown by patient.

GI: No nausea or vomiting, reflux controlled, No abd pain, no changes in bowel/bladder pattern. She uses fiber as a daily laxative to prevent constipation.

GU: no change in her urinary pattern, dysuria, or incontinence. She is heterosexual. She has had a total abd hysterectomy. No history of STD’s or HPV. She has not been sexually active since the death of her husband.

MS: she has no arthralgia/myalgia, no arthritis, gout or limitation in her range of motion by report. No history of trauma or fractures.

Psych: no history of anxiety or depression. No sleep disturbance, delusions or mental health history. She denied suicidal/homicidal history.

Neuro: no syncopal episodes or dizziness, no paresthesia, head aches. No change in memory or thinking patterns; no twitches or abnormal movements; no history of gait disturbance or problems with coordination. No falls or seizure history.

Integument/Heme/Lymph: no rashes, itching, or bruising. She uses lotion to prevent dry skin. She has no history of skin cancer or lesion removal. She has no bleeding disorders, clotting difficulties or history of transfusions.

Endocrine: no endocrine symptoms or hormone therapies.

Allergic/Immunologic: this has hx of allergic rhinitis, but no known immune deficiencies. Her last HIV test was 10 years ago.

OBJECTIVE DATA

Physical Exam:

Vital signs: B/P 110/72, left arm, sitting, regular cuff; P 70 and regular; T 98.3 Orally; RR 16; non-labored; Wt: 115 lbs; Ht: 5’2; BMI 21

General: A&O x3, NAD, appears mildly uncomfortable

HEENT: PERRLA, EOMI, oronasopharynx is clear

Neck: Carotids no bruit, jvd or tmegally

Chest/Lungs: CTA AP&L

Heart/Peripheral Vascular: RRR without murmur, rub or gallop; pulses+2 bilat pedal and +2 radial

ABD: benign, nabs x 4, no organomegaly; mild suprapubic tenderness – diffuse – no rebound

Genital/Rectal: external genitalia intact, no cervical motion tenderness, no adnexal masses.

Musculoskeletal: symmetric muscle development – some age related atrophy; muscle strengths 5/5 all groups.

Neuro: CN II – XII grossly intact, DTR’s intact

Skin/Lymph Nodes: No edema, clubbing, or cyanosis; no palpable nodes

ASSESSMENT:

Lab Tests and Results:

CBC – WBC 15,000 with + left shift

SAO2 – 98%

Diagnostics:

Lab:

Radiology:

CXR – cardiomegaly with air trapping and increased AP diameter

ECG

Normal sinus rhythm

Differential Diagnosis (DDx):

1.) Acute Bronchitis

2.) Pulmonary Embolis

3.) Lung Cancer

Diagnoses/Client Problems:

1.) COPD

2.) HTN, controlled

3.) Tobacco abuse – 40 pack year history

4.) Allergy to sulfa drugs – rash

5.) GERD – quiet on no current medication

PLAN: [This section is not required for the assignments in this course, but will be required for future courses.]

 

ADDITIONAL INSTRUCTIONS FOR THE CLASS

Who We Are 

We are a professional custom writing website. If you have searched for a question and bumped into our website just know you are in the right place to get help with your coursework.

Do you handle any type of coursework?

Yes. We have posted our previous orders to display our experience. Since we have done this question before, we can also do it for you. To make sure we do it perfectly, please fill out our Order Form. Filling the order form correctly will assist our team in referencing, specifications, and future communication.

Is it hard to Place an Order?

  • 1. Click on “Order Now” on the main Menu and a new page will appear with an order form to be filled.
  • 2. Fill in your paper’s requirements in the “PAPER INFORMATION” section and the system will calculate your order price/cost.
  • 3. Fill in your paper’s academic level, deadline, and the required number of pages from the drop-down menus.
  • 4. Click “FINAL STEP” to enter your registration details and get an account with us for record-keeping and then, click on “PROCEED TO CHECKOUT” at the bottom of the page.
  • 5. From there, the payment sections will show, follow the guided payment process and your order will be available for our writing team to work on it.

SCORE A+ WITH HELP FROM OUR PROFESSIONAL WRITERS – Comprehensive SOAP Exemplar

We will process your orders through multiple stages and checks to ensure that what we are delivering to you, in the end, is something that is precise as you envisioned it. All of our essay writing service products are 100% original, ensuring that there is no plagiarism in them. The sources are well-researched and cited so it is interesting. Our goal is to help as many students as possible with their assignments, i.e. our prices are affordable and services premium.

  • Discussion Questions (DQ)

Initial responses to the DQ should address all components of the questions asked, including a minimum of one scholarly source, and be at least 250 words. Successful responses are substantive (i.e., add something new to the discussion, engage others in the discussion, well-developed idea) and include at least one scholarly source. One or two-sentence responses, simple statements of agreement or “good post,” and responses that are off-topic will not count as substantive. Substantive responses should be at least 150 words. I encourage you to incorporate the readings from the week (as applicable) into your responses. Comprehensive SOAP Template

  • Weekly Participation

Your initial responses to the mandatory DQ do not count toward participation and are graded separately. In addition to the DQ responses, you must post at least one reply to peers (or me) on three separate days, for a total of three replies. Participation posts do not require a scholarly source/citation (unless you cite someone else’s work). Part of your weekly participation includes viewing the weekly announcement and attesting to watching it in the comments. These announcements are made to ensure you understand everything that is due during the week. Comprehensive SOAP Template

  • APA Format and Writing Quality

Familiarize yourself with the APA format and practice using it correctly. It is used for most writing assignments for your degree. Visit the Writing Center in the Student Success Center, under the Resources tab in Loud-cloud for APA paper templates, citation examples, tips, etc. Points will be deducted for poor use of APA format or absence of APA format (if required). Cite all sources of information! When in doubt, cite the source. Paraphrasing also requires a citation. I highly recommend using the APA Publication Manual, 6th edition.

  • Use of Direct Quotes

I discourage over-utilization of direct quotes in DQs and assignments at the Master’s level and deduct points accordingly. As Masters’ level students, it is important that you be able to critically analyze and interpret information from journal articles and other resources. Simply restating someone else’s words does not demonstrate an understanding of the content or critical analysis of the content. It is best to paraphrase content and cite your source. Comprehensive SOAP Exemplar

  • LopesWrite Policy

For assignments that need to be submitted to Lopes Write, please be sure you have received your report and Similarity Index (SI) percentage BEFORE you do a “final submit” to me. Once you have received your report, please review it. This report will show you grammatical, punctuation, and spelling errors that can easily be fixed. Take the extra few minutes to review instead of getting counted off for these mistakes. Review your similarities. Did you forget to cite something? Did you not paraphrase well enough? Is your paper made up of someone else’s thoughts more than your own? Visit the Writing Center in the Student Success Center, under the Resources tab in Loud-cloud for tips on improving your paper and SI score.

  • Late Policy

The university’s policy on late assignments is a 10% penalty PER DAY LATE. This also applies to late DQ replies. Please communicate with me if you anticipate having to submit an assignment late. I am happy to be flexible, with advance notice. We may be able to work out an extension based on extenuating circumstances. If you do not communicate with me before submitting an assignment late, the GCU late policy will be in effect. I do not accept assignments that are two or more weeks late unless we have worked out an extension. As per policy, no assignments are accepted after the last day of class. Any assignment submitted after midnight on the last day of class will not be accepted for grading.

  • Communication

Communication is so very important. There are multiple ways to communicate with me: Questions to Instructor Forum: This is a great place to ask course content or assignment questions. If you have a question, there is a good chance one of your peers does as well. This is a public forum for the class. Individual Forum: This is a private forum to ask me questions or send me messages. This will be checked at least once every 24 hours. Comprehensive SOAP Template

  • Guarantee
    Comprehensive SOAP Exemplar
    Comprehensive SOAP Exemplar

  • Zero Plagiarism
  • On-time delivery
  • A-Grade Papers
  • Free Revision
  • 24/7 Support
  • 100% Confidentiality
  • Professional Writers

  • Services Offered

  • Multiple answer questions

    • SCORE A+ WITH HELP FROM OUR PROFESSIONAL WRITERS Comprehensive SOAP Exemplar

    We will process your orders through multiple stages and checks to ensure that what we are delivering to you, in the end, is something that is precise as you envisioned it. All of our essay writing service products are 100% original, ensuring that there is no plagiarism in them. The sources are well-researched and cited so it is interesting. Our goal is to help as many students as possible with their assignments, i.e. our prices are affordable and services premium.

    Looking for a Similar Assignment? Order a custom-written, plagiarism-free paper

    • Custom paper writing
    • Question and answers
    • Essay paper writing
    • Editing and proofreading
    • Plagiarism removal services
    • Multiple answer questions

    SCORE A+ WITH HELP FROM OUR PROFESSIONAL WRITERS Comprehensive SOAP Exemplar

    We will process your orders through multiple stages and checks to ensure that what we are delivering to you, in the end, is something that is precise as you envisioned it. All of our essay writing service products are 100% original, ensuring that there is no plagiarism in them. The sources are well-researched and cited so it is interesting. Our goal is to help as many students as possible with their assignments, i.e. our prices are affordable and services premium.

    Looking for a Similar Assignment? Order a custom-written, plagiarism-free paper

    Comprehensive SOAP Template

    Comprehensive SOAP Template

    Comprehensive SOAP Template

    Comprehensive SOAP Template

    Patient Initials: _______ Age: _______ Gender: _______

    Note: The mnemonic below is included for your reference and should be removed before the submission of your final note.

    O = onset of symptom (acute/gradual)

    L= location

    D= duration (recent/chronic)

    C= character

    A= associated symptoms/aggravating factors

    R= relieving factors

    T= treatments previously tried – response? Why discontinued?

    S= severity

    SUBJECTIVE DATA: Include what the patient tells you, but organize the information.

    Chief Complaint (CC): In just a few words, explain why the patient came to the clinic.

    History of Present Illness (HPI): This is the symptom analysis section of your note. Thorough documentation in this section is essential for patient care, coding, and billing analysis. Paint a picture of what is wrong with the patient. You need to start EVERY HPI with age, race, and gender (i.e. 34-year-old AA male). You must include the 7 attributes of each principal symptom:

    1. Location

    2. Quality

    3. Quantity or severity

    4. Timing, including onset, duration, and frequency

    5. Setting in which it occurs

    6. Factors that have aggravated or relieved the symptom

    7. Associated manifestations

    Medications: Include over the counter, vitamin, and herbal supplements. List each one by name with dosage and frequency.

    Allergies: Include specific reactions to medications, foods, insects, and environmental factors.

    Past Medical History (PMH): Include illnesses (also childhood illnesses), hospitalizations, and risky sexual behaviors.

    Past Surgical History (PSH): Include dates, indications, and types of operations

    Sexual/Reproductive History: If applicable, include obstetric history, menstrual history, methods of contraception, and sexual function.

    Personal/Social History: Include tobacco use, alcohol use, drug use, patient’s interests, ADL’s and IADL’s if applicable, and exercise and eating habits.

    Immunization History: Include last Tdp, Flu, pneumonia, etc.

    Significant Family History: Include history of parents, Grandparents, siblings, and children.

    Lifestyle: Include cultural factors, economic factors, safety, and support systems.

    Review of Systems: From head-to-toe, include each system that covers the Chief Complaint, History of Present Illness, and History (this includes the systems that address any previous diagnoses). Remember that the information you include in this section is based on what the patient tells you. You do not need to do them all unless you are doing a total H&P. To ensure that you include all essentials in your case, refer to Chapter 2 of the Sullivan text.

    General: Include any recent weight changes, weakness, fatigue, or fever, but do not restate HPI data here.

    HEENT:

    Neck:

    Breasts:

    Respiratory:

    Cardiovascular/Peripheral Vascular:

    Gastrointestinal:

    Genitourinary:

    Musculoskeletal:

    Psychiatric:

    Neurological:

    Skin: Include rashes, lumps, sores, itching, dryness, changes, etc.

    Hematologic:

    Endocrine:

    Allergic/Immunologic:

    OBJECTIVE DATA: From head-to-toe, include what you see, hear, and feel when doing your physical exam. You only need to examine the systems that are pertinent to the CC, HPI, and History unless you are doing a total H&P. Do not use WNL or normal. You must describe what you see.

    Physical Exam:

    Vital signs: Include vital signs, ht, wt, and BMI.

    General: Include general state of health, posture, motor activity, and gait. This may also include dress, grooming, hygiene, odors of body or breath, facial expression, manner, level of conscience, and affect and reactions to people and things.

    HEENT:

    Neck:

    Chest/Lungs: Always include this in your PE.

    Heart/Peripheral Vascular: Always include the heart in your PE.

    Abdomen:

    Genital/Rectal:

    Musculoskeletal:

    Neurological:

    Skin:

    ASSESSMENT: List your priority diagnosis(es). For each priority diagnosis, list at least 3 differential diagnoses, each of which must be supported with evidence and guidelines. Include any labs, x-rays, or other diagnostics that are needed to develop the differential diagnoses. For holistic care, you need to include previous diagnoses and indicate whether these are controlled or not controlled. These should also be included in your treatment plan.

    PLAN: This section is not required for the assignments in this course (NURS 6512), but will be required for future courses.

    Treatment Plan: If applicable, include both pharmacological and nonpharmacological strategies, alternative therapies, follow-up recommendations, referrals, consultations, and any additional labs, x-ray, or other diagnostics. Support the treatment plan with evidence and guidelines.

    Health Promotion: Include exercise, diet, and safety recommendations, as well as any other health promotion strategies for the patient/family. Support the health promotion recommendations and strategies with evidence and guidelines.

    Disease Prevention: As appropriate for the patient’s age, include disease prevention recommendations and strategies such as fasting lipid profile, mammography, colonoscopy, immunizations, etc. Support the disease prevention recommendations and strategies with evidence and guidelines.

    REFLECTION: Reflect on your clinical experience and consider the following questions: What did you learn from this experience? What would you do differently? Do you agree with your preceptor based on the evidence?

    Comprehensive SOAP Exemplar

    Purpose: To demonstrate what each section of the SOAP note should include. Remember that Nurse Practitioners treat patients in a holistic manner and your SOAP note should reflect that premise.

    Patient Initials: _______ Age: _______ Gender: _______

    SUBJECTIVE DATA:

    Chief Complaint (CC): Coughing up phlegm and fever

    History of Present Illness (HPI): Sara Jones is a 65 year old Caucasian female who presents today with a productive cough x 3 weeks and fever for the last three days. She reported that the “cold feels like it is descending into her chest”. The cough is nagging and productive. She brought in a few paper towels with expectorated phlegm – yellow/brown in color. She has associated symptoms of dyspnea of exertion and fever. Her Tmax was reported to be 102.4, last night. She has been taking Ibuprofen 400mg about every 6 hours and the fever breaks, but returns after the medication wears off. She rated the severity of her symptom discomfort at 4/10.

    Medications:

    1.) Lisinopril 10mg daily

    2.) Combivent 2 puffs every 6 hours as needed

    3.) Serovent daily

    4.) Salmeterol daily

    5.) Over the counter Ibuprofen 200mg -2 PO as needed

    6.) Over the counter Benefiber

    7.) Flonase 1 spray each night as needed for allergic rhinitis symptoms

    Allergies:

    Sulfa drugs – rash

    Past Medical History (PMH):

    1.) Emphysema with recent exacerbation 1 month ago – deferred admission – RX’d with outpatient antibiotics and an hand held nebulizer treatments.

    2.) Hypertension – well controlled

    3.) Gastroesophageal reflux (GERD) – quiet on no medication

    4.) Osteopenia

    5.) Allergic rhinitis

    Past Surgical History (PSH):

    1.) Cholecystectomy 1994

    2.) Total abdominal hysterectomy (TAH) 1998

    Sexual/Reproductive History:

    Heterosexual

    G1P1A0

    Non-menstrating – TAH 1998

    Personal/Social History:

    She has smoked 2 packs of cigarettes daily x 30 years; denied ETOH or illicit drug use.

    Immunization History:

    Her immunizations are up to date. She received the influenza vaccine last November and the Pneumococcal vaccine at the same time.

    Significant Family History:

    Two brothers – one with diabetes, dx at age 65 and the other with prostate CA, dx at age 62. She has 1 daughter, in her 50’s, healthy, living in nearby neighborhood.

    Lifestyle:

    She is a retired; widowed x 8 years; lives in the city, moderate crime area, with good public transportation. She college graduate, owns her home and receives a pension of $50,000 annually – financially stable.

    She has a primary care nurse practitioner provider and goes for annual and routine care twice annually and as needed for episodic care. She has medical insurance but often asks for drug samples for cost savings. She has a healthy diet and eating pattern. There are resources and community groups in her area at the senior center and she attends regularly. She enjoys bingo. She has a good support system composed of family and friends.

    Review of Systems:

    General: + fatigue since the illness started; + fever, no chills or night sweats; no recent weight gains of losses of significance.

    HEENT: no changes in vision or hearing; she does wear glasses and her last eye exam was 1 ½ years ago. She reported no history of glaucoma, diplopia, floaters, excessive tearing or photophobia. She does have bilateral small cataracts that are being followed by her ophthalmologist. She has had no recent ear infections, tinnitus, or discharge from the ears. She reported her sense of smell is intact. She has not had any episodes of epistaxis. She does not have a history of nasal polyps or recent sinus infection. She has history of allergic rhinitis that is seasonal. Her last dental exam was 3/2014. She denied ulceration, lesions, gingivitis, gum bleeding, and has no dental appliances. She has had no difficulty chewing or swallowing.

    Neck: no pain, injury, or history of disc disease or compression. Her last Bone Mineral density (BMD) test was 2013 and showed mild osteopenia, she said.

    Breasts: No reports of breast changes. No history of lesions, masses or rashes. No history of abnormal mammograms.

    Repiratory: + cough and sputum production (see HPI); denied hemoptysis, no difficulty breathing at rest; + dyspnea on exertion; she has history of COPD and community acquired pneumonia 2012. Last PPD was 2013. Last CXR – 1 month ago.

    CV: no chest discomfort, palpitations, history of murmur; no history of arrhythmias, orthopnea, paroxysmal nocturnal dyspnea, edema, or claudication. Date of last ECG/cardiac work up is unknown by patient.

    GI: No nausea or vomiting, reflux controlled, No abd pain, no changes in bowel/bladder pattern. She uses fiber as a daily laxative to prevent constipation.

    GU: no change in her urinary pattern, dysuria, or incontinence. She is heterosexual. She has had a total abd hysterectomy. No history of STD’s or HPV. She has not been sexually active since the death of her husband.

    MS: she has no arthralgia/myalgia, no arthritis, gout or limitation in her range of motion by report. No history of trauma or fractures.

    Psych: no history of anxiety or depression. No sleep disturbance, delusions or mental health history. She denied suicidal/homicidal history.

    Neuro: no syncopal episodes or dizziness, no paresthesia, head aches. No change in memory or thinking patterns; no twitches or abnormal movements; no history of gait disturbance or problems with coordination. No falls or seizure history.

    Integument/Heme/Lymph: no rashes, itching, or bruising. She uses lotion to prevent dry skin. She has no history of skin cancer or lesion removal. She has no bleeding disorders, clotting difficulties or history of transfusions.

    Endocrine: no endocrine symptoms or hormone therapies.

    Allergic/Immunologic: this has hx of allergic rhinitis, but no known immune deficiencies. Her last HIV test was 10 years ago.

    OBJECTIVE DATA

    Physical Exam:

    Vital signs: B/P 110/72, left arm, sitting, regular cuff; P 70 and regular; T 98.3 Orally; RR 16; non-labored; Wt: 115 lbs; Ht: 5’2; BMI 21

    General: A&O x3, NAD, appears mildly uncomfortable

    HEENT: PERRLA, EOMI, oronasopharynx is clear

    Neck: Carotids no bruit, jvd or tmegally

    Chest/Lungs: CTA AP&L

    Heart/Peripheral Vascular: RRR without murmur, rub or gallop; pulses+2 bilat pedal and +2 radial

    ABD: benign, nabs x 4, no organomegaly; mild suprapubic tenderness – diffuse – no rebound

    Genital/Rectal: external genitalia intact, no cervical motion tenderness, no adnexal masses.

    Musculoskeletal: symmetric muscle development – some age related atrophy; muscle strengths 5/5 all groups.

    Neuro: CN II – XII grossly intact, DTR’s intact

    Skin/Lymph Nodes: No edema, clubbing, or cyanosis; no palpable nodes

    ASSESSMENT:

    Lab Tests and Results:

    CBC – WBC 15,000 with + left shift

    SAO2 – 98%

    Diagnostics:

    Lab:

    Radiology:

    CXR – cardiomegaly with air trapping and increased AP diameter

    ECG

    Normal sinus rhythm

    Differential Diagnosis (DDx):

    1.) Acute Bronchitis

    2.) Pulmonary Embolis

    3.) Lung Cancer

    Diagnoses/Client Problems:

    1.) COPD

    2.) HTN, controlled

    3.) Tobacco abuse – 40 pack year history

    4.) Allergy to sulfa drugs – rash

    5.) GERD – quiet on no current medication

    PLAN: [This section is not required for the assignments in this course, but will be required for future courses.]

     

    ADDITIONAL INSTRUCTIONS FOR THE CLASS

    Who We Are 

    We are a professional custom writing website. If you have searched for a question and bumped into our website just know you are in the right place to get help with your coursework.

    Do you handle any type of coursework?

    Yes. We have posted our previous orders to display our experience. Since we have done this question before, we can also do it for you. To make sure we do it perfectly, please fill out our Order Form. Filling the order form correctly will assist our team in referencing, specifications, and future communication.

    Is it hard to Place an Order?

    • 1. Click on “Order Now” on the main Menu and a new page will appear with an order form to be filled.
    • 2. Fill in your paper’s requirements in the “PAPER INFORMATION” section and the system will calculate your order price/cost.
    • 3. Fill in your paper’s academic level, deadline, and the required number of pages from the drop-down menus.
    • 4. Click “FINAL STEP” to enter your registration details and get an account with us for record-keeping and then, click on “PROCEED TO CHECKOUT” at the bottom of the page.
    • 5. From there, the payment sections will show, follow the guided payment process and your order will be available for our writing team to work on it.

    SCORE A+ WITH HELP FROM OUR PROFESSIONAL WRITERS – Comprehensive SOAP Template

    We will process your orders through multiple stages and checks to ensure that what we are delivering to you, in the end, is something that is precise as you envisioned it. All of our essay writing service products are 100% original, ensuring that there is no plagiarism in them. The sources are well-researched and cited so it is interesting. Our goal is to help as many students as possible with their assignments, i.e. our prices are affordable and services premium.

    • Discussion Questions (DQ)

    Initial responses to the DQ should address all components of the questions asked, including a minimum of one scholarly source, and be at least 250 words. Successful responses are substantive (i.e., add something new to the discussion, engage others in the discussion, well-developed idea) and include at least one scholarly source. One or two-sentence responses, simple statements of agreement or “good post,” and responses that are off-topic will not count as substantive. Substantive responses should be at least 150 words. I encourage you to incorporate the readings from the week (as applicable) into your responses. Comprehensive SOAP Template

    • Weekly Participation

    Your initial responses to the mandatory DQ do not count toward participation and are graded separately. In addition to the DQ responses, you must post at least one reply to peers (or me) on three separate days, for a total of three replies. Participation posts do not require a scholarly source/citation (unless you cite someone else’s work). Part of your weekly participation includes viewing the weekly announcement and attesting to watching it in the comments. These announcements are made to ensure you understand everything that is due during the week. Comprehensive SOAP Template

    • APA Format and Writing Quality

    Familiarize yourself with the APA format and practice using it correctly. It is used for most writing assignments for your degree. Visit the Writing Center in the Student Success Center, under the Resources tab in Loud-cloud for APA paper templates, citation examples, tips, etc. Points will be deducted for poor use of APA format or absence of APA format (if required). Cite all sources of information! When in doubt, cite the source. Paraphrasing also requires a citation. I highly recommend using the APA Publication Manual, 6th edition.

    • Use of Direct Quotes

    I discourage over-utilization of direct quotes in DQs and assignments at the Master’s level and deduct points accordingly. As Masters’ level students, it is important that you be able to critically analyze and interpret information from journal articles and other resources. Simply restating someone else’s words does not demonstrate an understanding of the content or critical analysis of the content. It is best to paraphrase content and cite your source.

    • LopesWrite Policy

    For assignments that need to be submitted to Lopes Write, please be sure you have received your report and Similarity Index (SI) percentage BEFORE you do a “final submit” to me. Once you have received your report, please review it. This report will show you grammatical, punctuation, and spelling errors that can easily be fixed. Take the extra few minutes to review instead of getting counted off for these mistakes. Review your similarities. Did you forget to cite something? Did you not paraphrase well enough? Is your paper made up of someone else’s thoughts more than your own? Visit the Writing Center in the Student Success Center, under the Resources tab in Loud-cloud for tips on improving your paper and SI score.

    • Late Policy

    The university’s policy on late assignments is a 10% penalty PER DAY LATE. This also applies to late DQ replies. Please communicate with me if you anticipate having to submit an assignment late. I am happy to be flexible, with advance notice. We may be able to work out an extension based on extenuating circumstances. If you do not communicate with me before submitting an assignment late, the GCU late policy will be in effect. I do not accept assignments that are two or more weeks late unless we have worked out an extension. As per policy, no assignments are accepted after the last day of class. Any assignment submitted after midnight on the last day of class will not be accepted for grading.

    • Communication

    Communication is so very important. There are multiple ways to communicate with me: Questions to Instructor Forum: This is a great place to ask course content or assignment questions. If you have a question, there is a good chance one of your peers does as well. This is a public forum for the class. Individual Forum: This is a private forum to ask me questions or send me messages. This will be checked at least once every 24 hours. Comprehensive SOAP Template

    • Guarantee
      Comprehensive SOAP Template
      Comprehensive SOAP Template

    • Zero Plagiarism
    • On-time delivery
    • A-Grade Papers
    • Free Revision
    • 24/7 Support
    • 100% Confidentiality
    • Professional Writers

    • Services Offered

    • Custom paper writing
    • Question and answers
    • Essay paper writing
    • Editing and proofreading
    • Plagiarism removal services
    • Multiple answer questions

    SCORE A+ WITH HELP FROM OUR PROFESSIONAL WRITERS Comprehensive SOAP Template

    We will process your orders through multiple stages and checks to ensure that what we are delivering to you, in the end, is something that is precise as you envisioned it. All of our essay writing service products are 100% original, ensuring that there is no plagiarism in them. The sources are well-researched and cited so it is interesting. Our goal is to help as many students as possible with their assignments, i.e. our prices are affordable and services premium.

    Looking for a Similar Assignment? Order a custom-written, plagiarism-free paper

    Assignment: Assessing the Genitalia and Rectum

    Lab Assignment: Assessing the Genitalia and Rectum

    GENITALIA ASSESSMENT

    Subjective:

    · CC: “I have bumps on my bottom that I want to have checked out.”

    · HPI: AB, a 21-year-old WF college student reports to your clinic with external bumps on her genital area. She states the bumps are painless and feel rough. She states she is sexually active and has had more than one partner during the past year. Her initial sexual contact occurred at age 18. She reports no abnormal vaginal discharge. She is unsure how long the bumps have been there but noticed them about a week ago. Her last Pap smear exam was 3 years ago, and no dysplasia was found; the exam results were normal. She reports one sexually transmitted infection (chlamydia) about 2 years ago. She completed the treatment for chlamydia as prescribed.

    · PMH: Asthma

    · Medications: Symbicort 160/4.5mcg

    · Allergies: NKDA

    · FH: No hx of breast or cervical cancer, Father hx HTN, Mother hx HTN, GERD

    · Social: Denies tobacco use; occasional etoh, married, 3 children (1 girl, 2 boys)

    Objective:

    · VS: Temp 98.6; BP 120/86; RR 16; P 92; HT 5’10”; WT 169lbs

    · Heart: RRR, no murmurs

    · Lungs: CTA, chest wall symmetrical

    · Genital: Normal female hair pattern distribution; no masses or swelling. Urethral meatus intact without erythema or discharge. Perineum intact. Vaginal mucosa pink and moist with rugae present, pos for firm, round, small, painless ulcer noted on external labia.

    · Abd: soft, normoactive bowel sounds, neg rebound, neg murphy’s, negMcBurney

    · Diagnostics: HSV specimen obtained

    Assessment:

    · Chancre

    Assignment: Lab Assignment: Assessing the Genitalia and Rectum

    Photo Credit: Getty Images

    Patients are frequently uncomfortable discussing with healthcare professional’s issues that involve the genitalia and rectum; however, gathering an adequate history and properly conducting a physical exam are vital. Examining case studies of genital and rectal abnormalities can help prepare advanced practice nurses to accurately assess patients with problems in these areas.

    In this Lab Assignment, you will analyze an Episodic note case study that describes abnormal findings in patients seen in a clinical setting. You will consider what history should be collected from the patients, as well as which physical exams and diagnostic tests should be conducted. You will also formulate a differential diagnosis with several possible conditions.

    To Prepare

    · Review the Episodic note case study your instructor provides you for this week’s Assignment. Please see the “Course Announcements” section of the classroom for your Episodic note case study.

    · Based on the Episodic note case study:

    · Review this week’s Learning Resources, and consider the insights they provide about the case study. Refer to Chapter 3 of the Sullivan resource to guide you as you complete your Lab Assignment.

    · Search the Walden library or the Internet for evidence-based resources to support your answers to the questions provided.

    · Consider what history would be necessary to collect from the patient in the case study.

    · Consider what physical exams and diagnostic tests would be appropriate to gather more information about the patient’s condition. How would the results be used to make a diagnosis?

    · Identify at least five possible conditions that may be considered in a differential diagnosis for the patient.

    The Lab Assignment

    Using evidence-based resources from your search, answer the following questions and support your answers using current evidence from the literature.

    · Analyze the subjective portion of the note. List additional information that should be included in the documentation.

    · Analyze the objective portion of the note. List additional information that should be included in the documentation.

    · Is the assessment supported by the subjective and objective information? Why or why not?

    · Would diagnostics be appropriate for this case, and how would the results be used to make a diagnosis?

    · Would you reject/accept the current diagnosis? Why or why not? Identify three possible conditions that may be considered as a differential diagnosis for this patient. Explain your reasoning using at least three different references from current evidence-based literature.

    Select Grid View or List View to change the rubric’s layout.

    Name: NURS_6512_Week_10_Assignment_Rubric

     

    Excellent

    Good

    Fair

    Poor

    With regard to the SOAP note case study provided and using evidence-based resources from your search, answer the following questions and support your answers using current evidence from the literature: ·   Analyze the subjective portion of the note. List additional information that should be included in the documentation.

    10 (10%) – 12 (12%)

    The response clearly, accurately, and thoroughly analyzes the subjective portion of the SOAP note and lists detailed additional information to be included in the documentation.

    7 (7%) – 9 (9%)

    The response accurately analyzes the subjective portion of the SOAP note and lists additional information to be included in the documentation.

    4 (4%) – 6 (6%)

    The response vaguely analyzes the subjective portion of the SOAP note and vaguely and/or inaccurately lists additional information to be included in the documentation.

    0 (0%) – 3 (3%)

    The response inaccurately analyzes the subjective portion of the SOAP note, with inaccurate and/or missing additional information included in the documentation.

    ·   Analyze the objective portion of the note. List additional information that should be included in the documentation.

    10 (10%) – 12 (12%)

    The response clearly, accurately, and thoroughly analyzes the objective portion of the SOAP note and lists detailed additional information to be included in the documentation.

    7 (7%) – 9 (9%)

    The response accurately analyzes the objective portion of the SOAP note and lists additional information to be included in the documentation.

    4 (4%) – 6 (6%)

    The response vaguely analyzes the objective portion of the SOAP note and vaguely and/or inaccurately lists additional information to be included in the documentation.

    0 (0%) – 3 (3%)

    The response inaccurately analyzes the objective portion of the SOAP note, with inaccurate and/or missing additional information included in the documentation.

    ·  Is the assessment supported by the subjective and objective information? Why or why not?

    14 (14%) – 16 (16%)

    The response clearly and accurately identifies whether or not the assessment is supported by the subjective and/or objective information, with a thorough and detailed explanation.

    11 (11%) – 13 (13%)

    The response accurately identifies whether or not the assessment is supported by the subjective and/or objective information, with a clear explanation.

    8 (8%) – 10 (10%)

    The response vaguely identifies whether or not the assessment is supported by the subjective and/or objective information, with a vague explanation.

    0 (0%) – 7 (7%)

    The response inaccurately identifies whether or not the assessment is supported by the subjective and/or objective information, with an inaccurate or missing explanation.

    ·   What diagnostic tests would be appropriate for this case, and how would the results be used to make a diagnosis?

    18 (18%) – 20 (20%)

    The response thoroughly and accurately describes appropriate diagnostic tests for the case and explains clearly, thoroughly, and accurately how the test results would be used to make a diagnosis.

    15 (15%) – 17 (17%)

    The response accurately describes appropriate diagnostic tests for the case and explains how the test results would be used to make a diagnosis.

    12 (12%) – 14 (14%)

    The response vaguely and/or with some inaccuracy describes appropriate diagnostic tests for the case and vaguely and/or with some inaccuracy explains how the test results would be used to make a diagnosis.

    0 (0%) – 11 (11%)

    The response inaccurately describes appropriate diagnostic tests for the case, with an inaccurate or missing explanation of how the test results would be used to make a diagnosis.

    ·   Would you reject or accept the current diagnosis? Why or why not? ·   Identify three possible conditions that may be considered as a differenial diagnosis for this patient. Explain your reasoning using at least three different references from current evidence-based literature.

    23 (23%) – 25 (25%)

    The response states clearly whether to accept or reject the current diagnosis, with a thorough, accurate, and detailed explanation of sound reasoning. The response clearly, thoroughly, and accurately identifies three conditions as a differential diagnosis, with reasoning that is explained clearly, accurately, and thoroughly using three or more different references from current evidence-based literature.

    20 (20%) – 22 (22%)

    The response states whether to accept or reject the current diagnosis, with an accurate explanation of sound reasoning. The response accurately identifies three conditions as a differential diagnosis, with reasoning that is explained using three different references from current evidence-based literature.

    17 (17%) – 19 (19%)

    The response states whether to accept or reject the current diagnosis, with a vague explanation of the reasoning. The response identifies two to three conditions as a differential diagnosis, with reasoning that is explained vaguely and/or inaccurately using three or fewer references from current evidence-based literature.

    0 (0%) – 16 (16%)

    The response inaccurately states or is missing a statement of whether to accept or reject the current diagnosis, with an explanation that is inaccurate and/or missing. The response identifies three or fewer conditions as a differential diagnosis, with reasoning that is missing or explained inaccurately using two or fewer references from current evidence-based literature.

    Written Expression and Formatting – Paragraph Development and Organization: Paragraphs make clear points that support well-developed ideas, flow logically, and demonstrate continuity of ideas. Sentences are carefully focused–neither long and rambling nor short and lacking substance. A clear and comprehensive purpose statement and introduction are provided that delineate all required criteria.

    5 (5%) – 5 (5%)

    Paragraphs and sentences follow writing standards for flow, continuity, and clarity. A clear and comprehensive purpose statement, introduction, and conclusion are provided that delineate all required criteria.

    4 (4%) – 4 (4%)

    Paragraphs and sentences follow writing standards for flow, continuity, and clarity 80% of the time. Purpose, introduction, and conclusion of the assignment are stated, yet are brief and not descriptive.

    3 (3%) – 3 (3%)

    Paragraphs and sentences follow writing standards for flow, continuity, and clarity 60%–79% of the time. Purpose, introduction, and conclusion of the assignment are vague or off topic.

    0 (0%) – 2 (2%)

    Paragraphs and sentences follow writing standards for flow, continuity, and clarity < 60% of the time. No purpose statement, introduction, or conclusion were provided.

    Written Expression and Formatting – English writing standards: Correct grammar, mechanics, and proper punctuation

    5 (5%) – 5 (5%)

    Uses correct grammar, spelling, and punctuation with no errors.

    4 (4%) – 4 (4%)

    Contains a few (1 or 2) grammar, spelling, and punctuation errors.

    3 (3%) – 3 (3%)

    Contains several (3 or 4) grammar, spelling, and punctuation errors.

    0 (0%) – 2 (2%)

    Contains many (≥ 5) grammar, spelling, and punctuation errors that interfere with the reader’s understanding.

    Written Expression and Formatting – The paper follows correct APA format for title page, headings, font, spacing, margins, indentations, page numbers, running heads, parenthetical/in-text citations, and reference list.

    5 (5%) – 5 (5%)

    Uses correct APA format with no errors.

    4 (4%) – 4 (4%)

    Contains a few (1 or 2) APA format errors.

    3 (3%) – 3 (3%)

    Contains several (3 or 4) APA format errors.

    0 (0%) – 2 (2%)

    Contains many (≥ 5) APA format errors.

    Total Points: 100

    ADDITIONAL INSTRUCTIONS FOR THE CLASS

    Who We Are 

    We are a professional custom writing website. If you have searched for a question and bumped into our website just know you are in the right place to get help with your coursework.

    Do you handle any type of coursework?

    Yes. We have posted our previous orders to display our experience. Since we have done this question before, we can also do it for you. To make sure we do it perfectly, please fill out our Order Form. Filling the order form correctly will assist our team in referencing, specifications, and future communication.

    Is it hard to Place an Order?

    • 1. Click on “Order Now” on the main Menu and a new page will appear with an order form to be filled.
    • 2. Fill in your paper’s requirements in the “PAPER INFORMATION” section and the system will calculate your order price/cost.
    • 3. Fill in your paper’s academic level, deadline, and the required number of pages from the drop-down menus.
    • 4. Click “FINAL STEP” to enter your registration details and get an account with us for record-keeping and then, click on “PROCEED TO CHECKOUT” at the bottom of the page.
    • 5. From there, the payment sections will show, follow the guided payment process and your order will be available for our writing team to work on it.

    SCORE A+ WITH HELP FROM OUR PROFESSIONAL WRITERS – Lab Assignment: Assessing the Genitalia and Rectum

    We will process your orders through multiple stages and checks to ensure that what we are delivering to you, in the end, is something that is precise as you envisioned it. All of our essay writing service products are 100% original, ensuring that there is no plagiarism in them. The sources are well-researched and cited so it is interesting. Our goal is to help as many students as possible with their assignments, i.e. our prices are affordable and services premium. NURS6512 Week 10 Assignment

    • Discussion Questions (DQ)

    Initial responses to the DQ should address all components of the questions asked, including a minimum of one scholarly source, and be at least 250 words. Successful responses are substantive (i.e., add something new to the discussion, engage others in the discussion, well-developed idea) and include at least one scholarly source. One or two-sentence responses, simple statements of agreement or “good post,” and responses that are off-topic will not count as substantive. Substantive responses should be at least 150 words. I encourage you to incorporate the readings from the week (as applicable) into your responses.

    • Weekly Participation

    Your initial responses to the mandatory DQ do not count toward participation and are graded separately. In addition to the DQ responses, you must post at least one reply to peers (or me) on three separate days, for a total of three replies. Participation posts do not require a scholarly source/citation (unless you cite someone else’s work). Part of your weekly participation includes viewing the weekly announcement and attesting to watching it in the comments. These announcements are made to ensure you understand everything that is due during the week. Lab Assignment: Assessing the Genitalia and Rectum

    • APA Format and Writing Quality

    Familiarize yourself with the APA format and practice using it correctly. It is used for most writing assignments for your degree. Visit the Writing Center in the Student Success Center, under the Resources tab in Loud-cloud for APA paper templates, citation examples, tips, etc. Points will be deducted for poor use of APA format or absence of APA format (if required). Cite all sources of information! When in doubt, cite the source. Paraphrasing also requires a citation. I highly recommend using the APA Publication Manual, 6th edition.

    • Use of Direct Quotes

    I discourage over-utilization of direct quotes in DQs and assignments at the Master’s level and deduct points accordingly. As Masters’ level students, it is important that you be able to critically analyze and interpret information from journal articles and other resources. Simply restating someone else’s words does not demonstrate an understanding of the content or critical analysis of the content. It is best to paraphrase content and cite your source. NURS6512 Week 10 Assignment

    • LopesWrite Policy

    For assignments that need to be submitted to Lopes Write, please be sure you have received your report and Similarity Index (SI) percentage BEFORE you do a “final submit” to me. Once you have received your report, please review it. This report will show you grammatical, punctuation, and spelling errors that can easily be fixed. Take the extra few minutes to review instead of getting counted off for these mistakes. Review your similarities. Did you forget to cite something? Did you not paraphrase well enough? Is your paper made up of someone else’s thoughts more than your own? Visit the Writing Center in the Student Success Center, under the Resources tab in Loud-cloud for tips on improving your paper and SI score.

    • Late Policy

    The university’s policy on late assignments is a 10% penalty PER DAY LATE. This also applies to late DQ replies. Please communicate with me if you anticipate having to submit an assignment late. I am happy to be flexible, with advance notice. We may be able to work out an extension based on extenuating circumstances. If you do not communicate with me before submitting an assignment late, the GCU late policy will be in effect. I do not accept assignments that are two or more weeks late unless we have worked out an extension. As per policy, no assignments are accepted after the last day of class. Any assignment submitted after midnight on the last day of class will not be accepted for grading. NURS6512 Week 10 Assignment

    • Communication

    Communication is so very important. There are multiple ways to communicate with me: Questions to Instructor Forum: This is a great place to ask course content or assignment questions. If you have a question, there is a good chance one of your peers does as well. This is a public forum for the class. Individual Forum: This is a private forum to ask me questions or send me messages. This will be checked at least once every 24 hours. NURS6512 Week 10 Assignment

    • Guarantee
      Lab Assignment: Assessing the Genitalia and Rectum
      Lab Assignment: Assessing the Genitalia and Rectum
    • Zero Plagiarism
    • On-time delivery
    • A-Grade Papers
    • Free Revision
    • 24/7 Support
    • 100% Confidentiality
    • Professional Writers
    • Services Offered
  • Multiple answer questions

    • SCORE A+ WITH HELP FROM OUR PROFESSIONAL WRITERS

    Lab Assignment: Assessing the Genitalia and Rectum

    We will process your orders through multiple stages and checks to ensure that what we are delivering to you, in the end, is something that is precise as you envisioned it. All of our essay writing service products are 100% original, ensuring that there is no plagiarism in them. The sources are well-researched and cited so it is interesting. Our goal is to help as many students as possible with their assignments, i.e. our prices are affordable and services premium.

    Looking for a Similar Assignment? Order a custom-written, plagiarism-free paper

    • Custom paper writing
    • Question and answers
    • Essay paper writing
    • Editing and proofreading
    • Plagiarism removal services
    • Multiple answer questions

    SCORE A+ WITH HELP FROM OUR PROFESSIONAL WRITERS

    Lab Assignment: Assessing the Genitalia and Rectum

    We will process your orders through multiple stages and checks to ensure that what we are delivering to you, in the end, is something that is precise as you envisioned it. All of our essay writing service products are 100% original, ensuring that there is no plagiarism in them. The sources are well-researched and cited so it is interesting. Our goal is to help as many students as possible with their assignments, i.e. our prices are affordable and services premium.

    Looking for a Similar Assignment? Order a custom-written, plagiarism-free paper