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Neurological Symptoms – 2025 Case Study 1 Headaches Neurological system and continue practicing documentation of a focused episodic SOAP note for Assignment A
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Neurological Symptoms – 2025
Case Study 1 Headaches: Neurological system and continue practicing documentation of a focused/episodic SOAP note for Assignment
A 20-year-old male complains of experiencing intermittent headaches. The headaches diffuse all over the head, but the greatest intensity and pressure occurs above the eyes and spreads through the nose, cheekbones, and jaw.
Episodic/Focused SOAP Note Template
Patient Information:
Initials, Age, Sex, Race
S.
CC (chief complaint) a BRIEF statement identifying why the patient is here – in the patient’s own words – for instance, “headache”, NOT “bad headache for 3 days”.
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. Use LOCATES Mnemonic to complete your HPI. You need to start EVERY HPI with age, race, and gender (e.g., 34-year-old AA male). You must include the seven attributes of each principal symptom in paragraph form, not a list. If the CC was “headache”, the LOCATES for the HPI might look like the following example:
Location: head
Onset: 3 days ago
Character: pounding, pressure around the eyes and temples
Associated signs and symptoms: nausea, vomiting, photophobia, phonophobia
Timing: after being on the computer all day at work
Exacerbating/ relieving factors: light bothers eyes, Aleve makes it tolerable but not completely better
Severity: 7/10 pain scale
Current Medications: include dosage, frequency, length of time used and reason for use; also include OTC or homeopathic products.
Allergies: include medication, food, and environmental allergies separately (a description of what the allergy is ie angioedema, anaphylaxis, etc. This will help determine a true reaction vs intolerance).
PMHx: include immunization status (note date of last tetanus for all adults), past major illnesses and surgeries. Depending on the CC, more info is sometimes needed
Soc Hx: include occupation and major hobbies, family status, tobacco & alcohol use (previous and current use), any other pertinent data. Always add some health promo question here – such as whether they use seat belts all the time or whether they have working smoke detectors in the house, living environment, text/cell phone use while driving, and support system.
Fam Hx: illnesses with possible genetic predisposition, contagious or chronic illnesses. The reason for the death of any deceased first degree relatives should be included. Include parents, grandparents, siblings, and children. Include grandchildren if pertinent.
ROS: cover all body systems that may help you include or rule out a differential diagnosis You should list each system as follows: General: Head: EENT: etc. You should list these in bullet format and document the systems in order from head to toe.
Example of Complete ROS:
GENERAL: No weight loss, fever, chills, weakness or fatigue.
HEENT: Eyes: No visual loss, blurred vision, double vision or yellow sclerae. Ears, Nose, Throat: No hearing loss, sneezing, congestion, runny nose or sore throat.
SKIN: No rash or itching.
CARDIOVASCULAR: No chest pain, chest pressure or chest discomfort. No palpitations or edema.
RESPIRATORY: No shortness of breath, cough or sputum.
GASTROINTESTINAL: No anorexia, nausea, vomiting or diarrhea. No abdominal pain or blood.
GENITOURINARY: Burning on urination. Pregnancy. Last menstrual period, MM/DD/YYYY.
NEUROLOGICAL: No headache, dizziness, syncope, paralysis, ataxia, numbness or tingling in the extremities. No change in bowel or bladder control.
MUSCULOSKELETAL: No muscle, back pain, joint pain or stiffness.
HEMATOLOGIC: No anemia, bleeding or bruising.
LYMPHATICS: No enlarged nodes. No history of splenectomy.
PSYCHIATRIC: No history of depression or anxiety.
ENDOCRINOLOGIC: No reports of sweating, cold or heat intolerance. No polyuria or polydipsia.
ALLERGIES: No history of asthma, hives, eczema or rhinitis.
O.
Physical exam: 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. Do not use “WNL” or “normal.” You must describe what you see. Always document in head to toe format i.e. General: Head: EENT: etc.
Diagnostic results: Include any labs, x-rays, or other diagnostics that are needed to develop the differential diagnoses (support with evidenced and guidelines)
A.
Differential Diagnoses (list a minimum of 3 differential diagnoses).Your primary or presumptive diagnosis should be at the top of the list. For each diagnosis, provide supportive documentation with evidence-based guidelines.
APA citation 4 to 5 Reference with 5 years.
NURSING WK DISCUSSIONS – 2025 Melissa Hinkhouse Week 5 Discussion Board Original Post Melissa Hinkhouse To be honest I have never had an interest in
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NURSING WK DISCUSSIONS – 2025
Melissa Hinkhouse
Week 5 Discussion Board Original Post
Melissa Hinkhouse
To be honest, I have never had an interest in creating a professional portfolio before reviewing this material. I thought this was something only actors and models did to showcase their headshots. I had never heard of a Curriculum Vitae. I had a fancy resume with my information types on it, I had even gone as far as had it printed on the extensive paper. Without having completed a portfolio, I understand why I was not selected for some positions I applied for.
I believe I first need to start with writing my Curriculum Vitae, as it states on the Walden Writing Centers Guide, curtail your Curriculum Vitae guide to the position you are applying for. This would go for your entire portfolio. I think the mean of it stays the same, but some minor adjustments to fit the position would be needed, highlight academic and accomplishments that relate to that area vs. another. Updated your resume is critical, including writing a specific job-related summary, I do not currently have an overview of my resume. Reviewing the articles on Professional Portfolios, my understanding is they are to display your progression and accomplishments along with your advancements and career path. It is to be a paper interview. I believe you have a few options to include academic activities and achievements. A person can list them in the Curriculum Vitae, which seems straight forward. Another option is they can be displayed by awards in a subcategory. A person can create an e-portfolio or a paper portfolio depending on the situation. There are so many options, by being creative, you show some of your personality through your individual collection.
References:
Thompson, T. L. (2011). Electronic portfolios for professional advancement. Clinical Nurse Specialist: The Journal for Advanced Nursing Practice, 25(4), 169–170.
Walden University (2018). Creating your curriculum vitae: A building block to your future. Retrieved from https://academicguides.waldenu.edu/careerservices/careerwebinars/resumesandCVs
Walden University. (2018). Curriculum Vitae guide: Build your curriculum vitae (c.v.). Retrieved from https://academicguides.waldenu.edu/careerservices/cvguide
Melissa Matejovsky RE: Discussion – Week 5
An academic portfolio is beneficial for a new scholar to maintain, as it highlights knowledge gained, support of evidence-based practice, and accomplishments. The portfolio exhibits not only past education but continued education within intended career field, which is felt to be linked with career development and salary (Casey & Egan, 2013). Portfolios can be in paper form or through a digital platform. It is estimated that 60 to 80% of perspective employers conduct online search of each candidate and it is recommended for all practicing profession/students to be aware of the digital presences across all platforms (Hannans & Olivo, 2017). In this digital age, it is important for everyone to be aware of the content posted or endorsed as it can be a direct reflection upon the person posting and cause limitations within a career if deemed inappropriate from perspective employers. The portfolio should demonstrate a commitment to continued competency within profession, should be unique to the person, clear and orderly, and should grow with the person across the lifespan of their career (Smith, 2011). It is important for each nursing professional to develop strategies for portfolio development and digital content.
Strategies Identified
The first strategy for portfolio development would be platform consideration. For students, some schools provide platforms such as Portfolium and Pathbrite, whereas, other social media platforms such as LinkedIn, Careerbuilder, or Monster.com (Hannans & Olivo, 2017). Social media platforms allow for the professional or student to not only highlight their accomplishments but connects them with other like professionals and opens a network of job opportunities. Again, it is important to remain aware of what digital content is being released as it can be a depiction of the posting individual. Some employers still require a resume or paper copies of career achievements, but it is good practice for networking to have a digital presence as well.
The second strategy for building a professional portfolio is remaining committed to professional development, advancement, and continuing education. This commitment enhances the portfolio development over the years but shows employers/network of colleagues, professional growth. Competency of nursing abilities remains the fundamental bases for quality patient care and positive outcomes (Karami, Farokhzadian, & Foroughameri, 2017). In the development of professional competencies, an organizational commitment develops which propels each professional forward into activities outside of their normal requirements (Karami, Farokhzadian, & Foroughameri, 2017). This strategy will continue to elevate each professional their commitment to professional growth increases.
Resources
Casey, D. & Egan, D. (2013). The use of professional portfolios for career enhancement. British Journal of Nursing, 15(11), 547-552. doi:10,12968/bjcn.2010.15.11.79625
Hannans, J. & Olivo, Y. (2017). Craft a positive nursing digital identity with an ePortfolio. American Nurse Today, 12(11), 48-49 hhtps://www.americannursetoday.com/wp-con-tent/uploads/2017/11/ant11-Digital-Identity-1017a-1.pdf
Karami, A., Farokhzadian, J., & Foroughameri, G. (2017). Nurses’ professional competency and organizational commitment: Is it important for human resource management? Plos One, 12(11). doi: 10.1371/journal.pone.0187863
Smith, L. S. (2011). Showcase your talents with a career portfolio. Nursing, 41(7), 54–56. doi: 10.1097/01.nurse.0000398641.62631.8e
EniolaOladokun RE: Discussion – Week 5COLLAPSE
A well-developed portfolio is a chronological, visual representation of your professional growth. The portfolio does not replace your curriculum vitae (CV) or resume, rather it is the supporting documentation that validates what you have stated on your CV. As a nurse scholar, successful branding is crucial to success in this industry and that is what will set you apart from your competitors. For this discussion, I have identified two strategies that will provide further details look at my accomplishments,
First, strategy is to make sure I have a current resume to showcase my education, achievements and to provide some background information. In the article” The use of professional portfolios for career enhancement”, Casey and Egan stated that it is important to include: “Biographical information, Educational background, Employment history, and professional qualification certificates” (Casey & Egan, 2013). This information provides an overview of what I currently have in my resume which includes my education, background and accomplishments which is a great way of introducing yourself to the people. Therefore, another key strategy is to plan on how and what would be the best way to layout all these pieces of documents to achieve the best display of your hard work in an organized and accurate manner.
Second strategy is through an online ePortfolio which is an online presentation or representation of my academic and professional experiences and achievements. An eportfolio is a way to show to potential employers how you want to be viewed professionally. “Rather than just a retrospective account of continuing professional development activities, a portfolio can be used as a vehicle for engaging in self-assessment and personal development planning. This online portfolio allows any employer to learn about the candidate’s
accomplishments whether they are a fit for the position before the face to face interview. My eportfolio helps me in demonstrating my wealth of experience and help substantiate what I am saying during an interview.
Casey, D. C. & Egan, D. (2013) The use of professional portfolios for career enhancement. British Journal of Community Nursing, 15(11), 547-552.
https://doi.org/10.12968/bjcn.2010.15.11.79625
Dennison, R.D (2017, June 26). What goes into your professional portfolio & what you’ll get out of it. Retrieved April 21, 2020 from http://
https://www.myamericannurse.com/what-goes-into-your-professional-portfolio-what-youll-get-out-of-it/
Walden University (2018). Creating your curriculum vitae: A building block to your future. Retrieved from
https://academicguides.waldenu.edu/careerservices/careerwebinars/resumesandCVs
Comprehensive Older Person Assessment – 2025 Comprehensive Older Person Assessment Complete the Comprehensive Older Person Assessment on a well non family member over the age of
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Comprehensive Older Person Assessment – 2025
Comprehensive Older Person Assessment
Complete the Comprehensive Older Person Assessment on a well, non-family member over the age of 70. Complete the Home Safety Checklist on their living environment.
Draw conclusions for the following areas:
Propose or develop health promotion teaching opportunities based upon findings related to deficits in activities of daily living, functional status, or any other issues in the evaluation form or home safety checklist.
Complete the Comprehensive Older Person Evaluation and the Home Safety Checklist on one non-family member over the age of 70 for this activity.
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Paper
Advanced Pharmacology Discussion Board – 2025 STATE FLORIDA Based on last week s reading you now have an idea of the role of the
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Advanced Pharmacology Discussion Board – 2025
STATE: FLORIDA.
Based on last week’s reading, you now have an idea of the role of the APRN, and legal/professional issues in prescribing. As a future nurse practitioner, you have the authority, based on your state nurse practice act, to prescribe medications for the patients for whom you will provide care, and the responsibility of prescriptive authority is more than just simply writing a prescription correctly.
Important Links:
https://www.flsenate.gov/Committees/BillSummaries/2016/html/1424
http://ojin.nursingworld.org/MainMenuCategories/ANAMarketplace/ANAPeriodicals/OJIN/TableofContents/Vol-19-2014/No2-May-2014/Barriers-to-NP-Practice.html
https://floridasnursing.gov/new-legislation-impacting-your-profession/
https://www.aanp.org/advocacy/advocacy-resource/position-statements/nurse-practitioner-prescriptive-privilege
Discuss the role of advanced practice nursing in safe prescribing and 3 prescribing barriers for APRNs.
STATE: FLORIDA.
A minimum of 2 paragraphs is required for all posts
Support all posts with at least 2 cited peer review references within 5 years of publication (references cannot be older than 5 years).
All posts are to be written in APA 7th edition format as required by the university.