SOAP Note 1 Week 4

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Instructions for Completing the SOAP Note

1. Review the SOAP note resources provided in the course content.

2. Read the Case Study: Begin by carefully reading the case study provided below. Pay close attention to the patient’s background, medical history, and presenting complaint.

3. Download the SOAP Form: Access the attached SOAP form. This form will serve as your template for documenting the patient encounter.

4. Complete the SOAP Form: Using the information from the case study, fill out the SOAP form to the best of your ability. Ensure that you provide details for each section: Subjective, Objective, Assessment, and Plan. Any part of the assessment not mentioned in the case study is considered normal.

5. Thoroughness is Key: Aim to complete each section of the SOAP form as comprehensively as possible. Include relevant information obtained from both the patient’s subjective account and objective observations.

6. Submit Your Completed SOAP Note: Once you have filled out the SOAP form, submit your completed document according to the instructions provided by your instructor. Include at least 2 reference.

CASE STUDY: Fever, Sore Throat, Fatigue

History

A.J. is a previously healthy 17-year-old female who presents to her primary care office due to fever, sore throat, fatigue, and cervical lymphadenopathy. Symptoms started 5 days ago and have been increasingly worse. She has been taking ibuprofen 200 mg every 6 to 8 hours which she states improves the fever and sore throat. She rates her current pain as 8/10. She reports that her brother had similar symptoms about 1 month ago. She denies weight loss, night sweats, other sites of lymph node enlargement, cough, rhinorrhea, abdominal pain, diarrhea, constipation, or rash. She has allergic rhinitis and takes Loratidine 10 mg PO daily. She has no drug allergies. She had a tonsillectomy at age 8. She has no significant family history. She denies smoking, recent travel, exposure to cats, or IV drug use. She is not sexually active and denies ever having intercourse. She is a high school student who is currently running track. She has had to miss practice due to illness.

Physical Examination

She appears ill. Her temperature is 101.8°F (38.7°C). Her pulse is 93 and her respirations are 18. Her weight is stable based on her previous visit. On physical examination, the clinician finds anterior cervical, posterior cervical, and axillary lymphadenopathy. Lymph nodes are bilateral, soft, mobile, and tender to palpation. The size of lymph nodes is estimated at 8 to 10 mm. She has no other superficial lymphadenopathy or splenomegaly on examination. Her posterior pharynx is erythematous without exudate. Tonsils are surgically removed. Her skin is clean, dry, and intact without any rashes, abrasions, or signs of infections. Heart rate and rhythm are regular and lungs are clear to auscultation bilaterally.

HNT

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Case Study: JE is a 38-year-old white woman with a 6-year history of psoriasis. Her family history includes allergies, asthma, and her mother with psoriasis. JE returns to the clinic today reporting an increase in symptoms and expresses a desire to improve the appearance of her skin.

Psoriasis:
Discuss the underlying pathophysiology of psoriasis, including the immune system’s role in the disease process.
Identify and describe common signs and symptoms of psoriasis.
Highlight potential treatment strategies aimed at managing symptoms and improving quality of life.
Describe evidence-based health promotion strategies for individuals with psoriasis, focusing on lifestyle modifications, prevention of symptom exacerbation, and mental health support.
Breast Health Conditions:
Intraductal papilloma
Explain the pathophysiology of the condition: Intraductal papilloma,
Describe the clinical presentation, including key signs and symptoms.
Discuss available diagnostic approaches and treatment options.
Outline specific health promotion strategies aimed at prevention, early detection, or management of the condition, emphasizing patient education and lifestyle interventions.
 

lesson 5 and 6

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Community health nurses work with populations that
vary from country to country, and to serve them
appropriately requires an understanding of the ways in
which the context in which they are located interacts
with their health status and health histories. Student
nurses are spending a month in Africa reviewing global
health and international community health nursing.
1. The student nurses are required to examine the
population in Africa to assess the kinds of health
conditions the population experiences. What is the
context and framework for delivering community-
based nursing within the context of global health?
2. The student nurses are examining the impact of
disease patterns on the health of the population of
Africa. What is the demographic transition theory,
and what demographic trends should the student
nurses expect to find in Africa based on this
theory?
3. The student nurses are exploring the social
determinants of health in Africa and how these
affect the global burden of disease in these
countries. What is the global burden of disease,
and how would the student nurses go about
calculating this metric for the countries in Africa
they are studying?

  1. Answers must:
    • Be 100 words or more
    • Use the standard English grammar and spelling
    • References are cited (if necessary)

Discussion

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  • Application of Course Knowledge: Answer all questions/criteria with explanations and detail.
    • Describe one source of big data that you are likely to use in your future advanced practice nursing role.  
    • Identify the types of information that can be obtained from this source.  
    • Examine three ways data from this source can be used to impact client care. 
    • Discuss the role of the advanced practice nurse in data stewardship. 

Nursing homework

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Weekly Clinical Experience 2

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Describe your clinical experience for this week

must be on Geriatrics patient 

  • Did you face any challenges, any success? If so, what were they?
  • Describe the assessment of a patient, detailing the signs and symptoms (S&S), assessment, plan of care, and at least 3 possible differential diagnosis with rationales.
  • Mention the health promotion intervention for this patient.
  • What did you learn from this week’s clinical experience that can beneficial for you as an advanced practice nurse?
  • Support your plan of care with the current peer-reviewed research guideline.

Submission Instructions:

  • Your initial post should be at least 500 words, formatted and cited in current APA style with support from at least 2 academic sources

Nursing Homework

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Case 1

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A 78-year-old female comes to your office escorted by a neighbor who is a patient of yours. The neighbor, who has lived next door to the older woman for years, relates that a week ago the elderly woman’s sister died and that she had been her caregiver for many years. The neighbor relates that although she would occasionally see the older woman, she did not visit the home. At the funeral last week, she noticed that the woman appeared fatigued, confused, sad, and gaunt in appearance. Later the neighbor approached the woman, inquired about her health, and determined that the woman had a very difficult time the past couple of months, caring alone for her sister until the end when hospice care was initiated. The neighbor convinced the woman to seek medical care and today is the first appointment with a provider that this 78-year-old female has had in 3 years. The older woman states that she is very fatigued and sad over the loss of her sister. Neither her sister nor the patient has been married. A distant niece came to the funeral but lives about 30 miles away. The woman states that she is not taking any prescription medication and relates no medical problems that she is aware of being diagnosed.

Vital signs: T 97.6°F, HR 98, RR 22, BP 95/60, BMI 21 

Chief Complaint: Fatigue and sadness over the death of her older sister.

Discuss the following:

1) What additional subjective information will you be asking the patient?
2) What additional objective findings would you be examining the patient for?
3) What are the differential diagnoses that you are considering?
4) What laboratory tests will help you rule out some of the differential diagnoses?
5) What screening tools will you select to use on this patient?
6) What is your plan of care?
7) What additional patient teaching may be needed?
8) Will you be looking for a consult?

Submission Instructions:

  • Your initial post should be at least 500 words, formatted and cited in current APA style with support from at least 2 academic sources.

PHE5015 – Week 2 Project

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Instructions attached

Discussion Topic: Discussion: When Ethics Conflict

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Purpose

This assignment is intended to help you learn to do the following:

  • Describe ethical considerations for healthcare professionals and medical researchers.
  • Apply ethical decision-making models to healthcare ethical dilemmas.
  • Evaluate legal issues in healthcare decision-making situations.

Action Items

  1. Read Ethics case: Should One Kind of Freedom Be Restricted to Promote Another?Links to an external site.
  2. Respond in a 150- to 200-word discussion post to the following prompts:
    • What are the ethical issues addressed in this case?
    • Which issues are ethics issues and which are medical decisions? Explain your answer.
    • Who needs to be involved in making the necessary decisions to move forward?
    • Answer the key questions posed in the article, “What factors can make the clinical benefits of restraints outweigh their harms, and how can restraints be effectively and ethically regulated and applied?” Explain your answer.
  3. By the due date indicated, create your initial post.
  4. By Sunday, respond to at least two of your classmates. Your response should be thoughtful and add to the learning.