Soap Note Assigment 2025

Patient information to complete the soap note. please see attachment 39-year-old Male with epigastric pain Chief Compliant: “I’ve been having this abdominal pain, and it just seems like it won’t go away. It started probably a year ago. It used to happen a few times a week, now it hurts every day.” History of Present Illness: Mr. Rodriguez is a 39-year-old male that recently immigrated to the United States from Dominican Republic. He complains of epigastric pain that began approximately one year ago. He describes the pain as “burning” and occurring daily. He states that the pain sometimes worsens with eating and sometimes it improves. He states that spicy foods make the pain worsen. He admits to weekly NSAID usage and drinking 3-4 alcoholic beverages a week. He quit smoking 6 months ago. He drinks an herbal tea but does not experience any relief or change in the symptoms. He denies any fever, chills, nausea, hematemesis, hematochezia, or melena. PMH/Medical/Surgical History: No history of gastrointestinal problems in the past. No history of surgery. No known drug allergies. Medications: Takes ibuprofen “almost daily” for aches and pains associated with working. Drinks herbal tea meant to improve GI symptoms. Significant Family History: Patient states family history of heart disease. Father had hypertension and his mother had diabetes. Social History : Patient denies smoking. Patient states that he quit smoking 6 months ago. Patient states that he drinks 3-4 beers weekly. No illicit drugs. Review of Symptoms: GENERAL: 39-year-old Spanish speaking patient. Language interpreter present. Patient is alert and oriented. Afebrile. Patient denies recent, unexplained weight loss, fever, chills, weakness or fatigue. HEENT: Denies headache, change in vision, nose, or ear problems. Denies sore throat. SKIN: No change in skin, hair or nails. CARDIOVASCULAR: Regular heart rate and rhythm. S1, S2, no murmurs, rubs, or gallops. RESPIRATORY: clear to auscultation. GASTROINTESTINAL: Soft, flat, non-distended. Normoactive bowel sounds heard in four quadrants. Soft, non-distended, with minimal epigastric tenderness on deep palpation without rebound tenderness or guarding, no hepatosplenomegaly, and no hernia or masses. GENITOURINARY: Denies problems with urination. NEUROLOGICAL: No headache, dizziness, syncope, paralysis, ataxia, numbness or tingling in the extremities. No change in bowel or bladder control. MUSCULOSKELETAL: Alert & oriented x3. Denies muscle, back pain, joint pain or stiffness. HEMATOLOGIC: Denies anemia, bleeding or bruising. LYMPHATICS: No enlarged nodes. Denies history of splenectomy. PSYCHIATRIC: Denies history of depression or anxiety. Patient does express concern about paying for medications and follow up visits due to lack of insurance. ENDOCRINOLOGIC: Denies sweating, cold or heat intolerance. Denies polyuria or polydipsia.. Objective Data: Temperature: 98.5 Fahrenheit Heart rate: 78 beats/minute, regular Respiratory rate: 16 breaths/minute Blood pressure: 133/82 mmHg Body Mass Index: 24.8 kg/m2- This BMI is within normal range according to the National Heart, Lung, and Blood Institute (2017). Physical Assessment Findings: Patient is alert, oriented and is cooperative. HEENT: PERRLA, no nystagmus noted. Tympanic membranes are intact. External auditory canals are normal. Oral pharynx is normal without erythema or exudate. Tongue and gums are normal. Lymph Nodes: Non-palpable Carotids: equal bilaterally 2+ Lungs: clear to auscultation Heart: Regular rate and rhythm normal S1 and S2. Abdomen: soft, non-tender, non-distended, no masses. Genital/Pelvic: unremarkable Extremities/Pulses: normal pulse bilaterally Neurologic: A&Ox3, cranial nerves intact Laboratory and Diagnostic Testing: Fecal Occult Blood Testing: negative Heliobacter Pylori (H. pylori) serology test: Positive CBC with differential to test for other conditions such as anemia or pancreatitis. Upper GI endoscopy: can help to check for damage to the lining of the stomach and to rule out malignancies (National Institutes of Health [NIH], 2017) Upper GI Series: Commonly used in the past to diagnose peptic ulcers however this test can miss smaller ulcers and does not allow for direct treatment of the ulcer (American College of Gastroenterology, 2017). Chest x-ray: This test is not normally used due more effective imaging for GI issues, but could be helpful to rule out other diagnoses such as a hiatal hernia or other abnormal anatomy (Chow, 2015). Diagnosis: K27 Peptic Ulcer Disease K21.9 Gastro-esophageal reflux disease without esophagitis K29.70 Gastritis, unspecified, without bleeding Source: ICD10Date.com, 2017. Differential Diagnosis : Diverticulitis Emergent Treatment of Gastroenteritis Esophageal Rupture and Tears in Emergency Medicine Esophagitis Gallstones (Cholelithiasis) Gastroesophageal Reflux Disease Inflammatory Bowel Disease Viral Hepatitis Acute Cholangitis Acute Coronary Syndrome Acute Gastritis Cholecystitis Cholecystitis and Biliary Colic in Emergency Medicine Chronic Gastritis Source: Epocrates, 2017. Plan of Care: Initially, this patient was started on over the counter antisecretory treatment such as an histamine-2 receptor antagonist or a proton pump inhibitor therapy (PPI) (NIH, 2014). At follow up, patient reported no relief in symptoms and tested positive for H. pylori. He was then treated with standard triple therapy (American Family Physician, 2015). At the next follow up he stated that symptoms resolved during antibiotic triple therapy but returned after finishing the regimen. He was then placed on salvage therapy with included another antibiotic, Levofloxacin, a PPI and amoxicillin for 10 days. At follow up the patient was completely symptom free. The patient was educated regarding possible continuation of PPI therapy to alleviate continuing symptoms. He was counseled to avoid NSAIDS, alcohol, spicy foods, smoking and to avoid lying down after eating (American Academy of Family Physicians [AAFP], 2015) The patient was counseled and educating using the services of a Spanish speaking interpreter and was given Spanish medication and treatment handouts. He was given instructions to recognize worsening symptoms and when to follow up in office. Medications: Triple Therapy: Omeprazole (PPI): 40mg PO QD for 4 weeks Amoxicillin: 1g PO BID for 10 days Clarithromycin 500mg PO BID for 10 days Second Line: Omeprazole (PPI): 40mg PO QD for 10 days Amoxicillin: 1g PO BID for 10 days Levofloxacin 500mg PO QD for 10days References: American Academy of Family Physicians (2015). Diagnosis and Treatment of Peptic Ulcer Disease and H. pylori Infection. American Family Physicians. 91(4):236-242. Retrieved from URL: https://www.aafp.org/afp/2015/0215/p236.htm American College of Gastroenterology (2017) Peptic Ulcer Disease. Digestive Health Topic. Retrieved from URL: http://patients.gi.org/topics/peptic-ulcer-disease/ Chow, S. (2015). Peptic Ulcer Diagnosis. News Medical Life Sciences. Retrieved from URL: https://www.news-medical.net/health/Peptic-Ulcer-Diagnosis.aspx Epocrates (2017). Peptic Ulcer Disease. Retrieved from URL: https://online.epocrates.com/diseases/8035/Peptic-ulcer-disease/Differential-Diagnosis ICD0Data.com (2017). Gastro-esophageal reflux disease without esophagitis. Retrieved fromhttp://www.icd10data.com/ICD10CM/Codes/K00-K95/K20-K31/K21-/K21.9 ICD10Data.com (2017). Peptic ulcer, site unspecified. Retrieved fromhttp://www.icd10data.com/ICD10CM/Codes/K00-K95/K20-K31/K27-/K27 ICD10Data.com (2017). Gastritis, unspecified, without bleeding. Retrieved from URL: http://www.icd10data.com/ICD10CM/Codes/K00-K95/K20-K31/K29-/K29.70 National Institutes of Health [NIH] (2017). Upper GI Endoscopy. Diagnostic Tests. Retrieved from URL: https://www.niddk.nih.gov/health-information/diagnostic-tests

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6512 Discussion wk 5 2025

Discussion: Assessing the Ears, Nose, and Throat Most ear, nose, and throat conditions that arise in non-critical care settings are minor in nature. However, subtle symptoms can sometimes escalate into life-threatening conditions that require prompt assessment and treatment. Nurses conducting assessments of the ears, nose, and throat must be able to identify the small differences between life-threatening conditions and benign ones. For instance, if a patient with a sore throat and a runny nose also has inflamed lymph nodes, the inflammation is probably due to the pathogen causing the sore throat rather than a case of throat cancer. With this knowledge and a sufficient patient health history, a nurse would not need to escalate the assessment to a biopsy or an MRI of the lymph nodes, but would probably perform a simple strep test. In this Discussion, you consider case studies of abnormal findings from patients in a clinical setting. You determine what history should be collected from the patients, what physical exams and diagnostic tests should be conducted, and formulate a differential diagnosis with several possible conditions. Note: By Day 1 of this week, your Instructor will have assigned you to one of the following specific case studies for this Discussion. Also, your Discussion post should be in the Episodic/Focused SOAP Note format, rather than the traditional narrative style Discussion posting format. Refer to Chapter 2 of the Sullivan text and the Episodic/Focused SOAP Template in the Week 5 Learning Resources for guidance. Remember that all Episodic/Focused SOAP notes have specific data included in every patient case. Case 1: Nose Focused Exam Richard is a 50-year-old male with nasal congestion, sneezing, rhinorrhea, and postnasal drainage. Richard has struggled with an itchy nose, eyes, palate, and ears for 5 days. As you check his ears and throat for redness and inflammation, you notice him touch his fingers to the bridge of his nose to press and rub there. He says he’s taken Mucinex OTC the past two nights to help him breathe while he sleeps. When you ask if the Mucinex has helped at all, he sneers slightly and gestures that the improvement is only minimal. Richard is alert and oriented. He has pale, boggy nasal mucosa with clear thin secretions and enlarged nasal turbinates, which obstruct airway flow but his lungs are clear. His tonsils are not enlarged but his throat is mildly erythematous. Case 2: Focused Throat Exam Lily is a 20-year-old student at the local community college. When some of her friends and classmates told her about an outbreak of flu-like symptoms sweeping her campus over the past two weeks, Lily figured she shouldn’t take her three-day sore throat lightly. Your clinic has treated a few cases similar to Lily’s. All the patients reported decreased appetite, headaches, and pain with swallowing. As Lily recounts these symptoms to you, you notice that she has a runny nose and a slight hoarseness in her voice but doesn’t sound congested. Case 3: Focused Ear Exam Martha brings her 11-year old grandson, James, to your clinic to have his right ear checked. He has complained to her about a mild earache for the past two days. His grandmother believes that he feels warm but did not verify this with a thermometer. James states that the pain was worse while he was falling asleep and that it was harder for him to hear. When you begin basic assessments, you notice that James has a prominent tan. When you ask him how he’s been spending his summer, James responds that he’s been spending a lot of time in the pool. To prepare: With regard to the case study you were assigned: · Review this week’s Learning Resources and consider the insights they provide. · Consider what history would be necessary to collect from the patient. · 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 5 possible conditions that may be considered in a differential diagnosis for the patient. Note: Before you submit your initial post, replace the subject line (“Week 5 Discussion”) with “Review of Case Study ___,” identifying the number of the case study you were assigned. Post an episodic/focused note about the patient in the case study to which you were assigned using the episodic/focused note template provided in week 5 resources. Provide evidence from the literature to support diagnostic tests that would be appropriate for each case. List five different possible conditions for the patient’s differential diagnosis and justify why you selected each.

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Case Study: Cardiorespiratory 2025

Evaluate the Health History and Medical Information for Mrs. J., presented below. Based on this information, formulate a conclusion based on your evaluation, and complete the Critical Thinking Essay assignment, as instructed below. Health History and Medical Information Health History Mrs. J. is a 63-year-old married woman who has a history of hypertension, chronic heart failure, and chronic obstructive pulmonary disease (COPD). Despite requiring 2L of oxygen/nasal cannula at home during activity, she continues to smoke two packs of cigarettes a day and has done so for 40 years. Three days ago, she had sudden onset of flu-like symptoms including fever, productive cough, nausea, and malaise. Over the past 3 days, she has been unable to perform ADLs and has required assistance in walking short distances. She has not taken her antihypertensive medications or medications to control her heart failure for 3 days. Today, she has been admitted to the hospital ICU with acute decompensated heart failure and acute exacerbation of COPD. Subjective Data 1. Is very anxious and asks whether she is going to die. 2. Denies pain but says she feels like she cannot get enough air. 3. Says her heart feels like it is “running away.” 4. Reports that she is exhausted and cannot eat or drink by herself. Objective Data 1. Height 175 cm; Weight 95.5kg. 2. Vital signs: T 37.6C, HR 118 and irregular, RR 34, BP 90/58. 3. Cardiovascular: Distant S1, S2, S3 present; PMI at sixth ICS and faint: all peripheral pulses are 1+; bilateral jugular vein distention; initial cardiac monitoring indicates a ventricular rate of 132 and atrial fibrillation. 4. Respiratory: Pulmonary crackles; decreased breath sounds right lower lobe; coughing frothy blood-tinged sputum; SpO2 82%. 5. Gastrointestinal: BS present: hepatomegaly 4cm below costal margin. Intervention The following medications administered through drug therapy control her symptoms: 1. IV furosemide (Lasix) 2. Enalapril (Vasotec) 3. Metoprolol (Lopressor) 4. IV morphine sulphate (Morphine) 5. Inhaled short-acting bronchodilator (ProAir HFA) 6. Inhaled corticosteroid (Flovent HFA) 7. Oxygen delivered at 2L/ NC Critical Thinking Essay In 850 words, critically evaluate Mrs. J.’s situation. Include the following: 1. Describe the clinical manifestations present in Mrs. J. 2. Discuss whether the nursing interventions at the time of her admissions were appropriate for Mrs. J. and explain the rationale for each of the medications listed. 3. Describe four cardiovascular conditions that may lead to heart failure and what can be done in the form of medical/nursing interventions to prevent the development of heart failure in each condition. 4. Taking into consideration the fact that most mature adults take at least six prescription medications, discuss four nursing interventions that can help prevent problems caused by multiple drug interactions in older patients. Provide a rationale for each of the interventions you recommend. 5. Provide a health promotion and restoration teaching plan for Mrs. J., including multidisciplinary resources for rehabilitation and any modifications that may be needed. Explain how the rehabilitation resources and modifications will assist the patients’ transition to independence. 6. Describe a method for providing education for Mrs. J. regarding medications that need to be maintained to prevent future hospital admission. Provide rationale. 7. Outline COPD triggers that can increase exacerbation frequency, resulting in return visits. Considering Mrs. J.’s current and long-term tobacco use, discuss what options for smoking cessation should be offered. You are required to cite to a minimum of two sources to complete this assignment. Sources must be published within the last 5 years and appropriate for the assignment criteria and relevant to nursing practice. Prepare this assignment according to the guidelines found in the APA Style Guide, and abstract is required.

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Write a 3-5 page blog post titled “Conflict and Power” that explains how individual perceptions of power can create conflict situations between law enforcement and members of a community. 2025

Write a 3-5 page blog post titled “Conflict and Power” that explains how individual perceptions of power can create conflict situations between law enforcement and members of a community. Use the relational theory of power to explain how perceptions affect the ability to resolve conflict. Then, identify a conflict resolution strategy and predict the outcome. Introduction Power plays a role in most conflicts. According to Coleman, Deutsch, and Marcus (2014), power can be understood by looking at its relationship to a situation and how that power is used. It is important to consider the role that each person in a conflict situation plays and that person’s place in the power hierarchy. Also, consider culture, as it can influence the way people react to power inequalities. Understanding these differences is key when trying to understand the dynamics of conflict and formulate strategies for conflict resolution. Reference Coleman, P., Deutsch, M., & Marcus, E. C. (Eds.). (2014). The handbook of conflict resolution: Theory and practice (3rd ed.). San Francisco, CA: Jossey-Bass. Demonstration of Proficiency By successfully completing this assessment, you will demonstrate your proficiency in the following course competencies and assessment criteria: Competency 1: Identify variables within an organizational structure that can promote conflict. Describe the factors that contribute to conflict between law enforcement and members of a community. Competency 2: Apply theoretical perspectives on conflict. Use the relational theory of power to explain how perceptions of power interfere with the ability to resolve conflict. Competency 3: Apply appropriate strategies to reduce or resolve conflicts. Identify conflict resolution strategies for law enforcement community conflicts. Competency 4: Analyze the impact of conflict on relationship building in face-to-face, virtual, cyber, and group communication. Explain how perceptions of power contribute to conflict situations. Competency 5: Evaluate the outcome of proposed strategies of conflict resolution. Determine the outcome of a conflict resolution strategy. Competency 6: Communicate effectively in a variety of formats. Write coherently to support a central idea in appropriate APA format with correct grammar, usage, and mechanics. Preparation Search the Capella library and the Internet to locate resources that address the dynamics of power and conflict (in particular, with relation to law enforcement), the relational theory of power, perceptions of power, and how things such as gender, culture, and ethnicity can affect that perception. Instructions Complete the following: Describe the factors or conditions that contribute to conflict situations between law enforcement and citizens. Explain how perceptions of power may contribute to conflict situations between law enforcement and members of a community. Be sure you consider the perceptions of both the police and individual citizens. Use the relational theory of power to explain how perceptions of power affect the ability to resolve police–community conflict. Identify strategies you believe might be effective in reducing or resolving conflicts between police and communities. Choose one strategy and determine the likely outcome. Although an actual blog would not have any specific formatting, format this assessment following APA guidelines. This format will facilitate faculty evaluation and feedback.

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