Shool requirements:

Turn it in Score must be less than 50%, must be your own work and in your own words,APA format, 

 Copy paste from websites or textbooks will not be accepted or tolerated. 

Please see College Handbook with reference to Academic Misconduct Statement.

Pick any Chronic Disease from Weeks 6-10: you can pick any of this condition,but have to be chonic not acute, cistic fibrosis,influenza,pleural effsuin,pulmonary embolism,tubercolosis,celiac disease,cirrhosis,divertiulitis,hepatitis encephalopathy,,hepatitis,pancreatic cancer,bladder cancer,prostate cancer,bph,prostatitis,cushing disease,addison disease,myasthemia gravis,priapis.ANY OF THAT CONDITIONS,JUST ONE,BUT CHONIC.

Sample:

SOAP NOTE SAMPLE FORMAT FOR MRC 

Name:  LP Date: Time: 1315   Age: 30 Sex: F SUBJECTIVE CC:   “I am having vaginal itching and pain in my lower abdomen.”  HPI:   Pt is a 30y/o AA female, who is a new patient that has recently moved to Miami.  She seeks treatment today after unsuccessful self-treatment of vaginal itching, burning upon urination, and lower abdominal pain.  She is concerned for the presence of a vaginal or bladder infection, or an STD.  Pt denies fever.  She reports the itching and burning with urination has been present for 3 weeks, and the abdominal pain has been intermittent since months ago.  Pt has tried OTC products for the itching, including Monistat and Vagisil.  She denies any other urinary symptoms, including urgency or frequency.  She describes the abdominal pain as either sharp or dull.  The pain level goes as high as 8 out of 10 at times.  200mg of PO Advil PRN reduces the pain to a 7/10.  Pt denies any aggravating factors for the pain.  Pt reports that she did start her menstrual cycle this morning, but denies any other discharge other that light bleeding beginning today.  Pt denies douching or the use of any vaginal irritants.  She reports that she is in a stable sexual relationship, and denies any new sexual partners in the last 90 days.  She denies any recent or historic known exposure to STDs.  She reports the use of condoms with every coital experience, as well as this being her only form of contraceptive.  She reports normal monthly menstrual cycles that last 3-4 days.  She reports dysmenorrhea, which she also takes Advil for.  She reports her last PAP smear was in 7/2016, was normal, and reports never having an abnormal PAP smear result.  Pt denies any hx of pregnancies.  Other medical hx includes GERD.  She reports that she has an Rx for Protonix, but she does not take it every day.  Her family hx includes the presence of DM and HTN.                 

Current Medications:  Protonix 40mg PO Daily for GERD MTV OTC PO Daily Advil 200mg OTC PO PRN for pain   

PMHx: Allergies:    NKA & NKDA 

Medication Intolerances:   Denies Chronic Illnesses/Major traumas  GERD Hospitalizations/Surgeries : Denies   

Family History :Father- DM & HTN; Mother- HTN; Older sister- DM & HTN; Maternal and paternal grandparents without known medical issues; 1 brother and 3 other sisters without known medical issues; No children.   

Social History:Lives alone.  Currently in a stable sexual relationship with one man.  Works for DEFACS.  Reports occasional alcohol use, but denies tobacco or illicit drug use.   

ROS General:  Denies weight change, fatigue, fever, night sweats Cardiovascular Denies chest pain and edema. Reports rare palpitations that are relieved by drinking water   

Skin:Denies any wounds, rashes, bruising, bleeding or skin discolorations, any changes in lesions  

Respiratory Denies cough. Reports dyspnea that accompanies the rare palpitations and is also relieved by drinking water   

Eyes Denies corrective lenses, blurring, visual changes of any kind  Gastrointestinal Abdominal pain (see HPI) and Hx of GERD.  Denies N/V/D, constipation, appetite changes   

Ears Denies Ear pain, hearing loss, ringing in ears  

Genitourinary/Gynecological Reports burning with urination, but denies frequency or urgency.  Contraceptive and STD prevention includes condoms with every coital event.  Current stable sexual relationship with one man.  Denies known historic or recent STD exposure. Last PAP was 7/2016 and normal. Regular monthly menstrual cycle lasting 3-4 days.    Nose/Mouth/Throat Denies sinus problems, dysphagia, nose bleeds or discharge  

Musculoskeletal Denies back pain, joint swelling, stiffness or pain 

Breast Denies SBE

Neurological Denies syncope, seizures, paralysis, weakness Heme/Lymph/Endo Denies bruising, night sweats, swollen glands

Psychiatric Denies depression, anxiety, sleeping difficulties 

OBJECTIVE Weight   140lb      Temp -97.7 BP 123/82 Height  5’4” Pulse 74

Respiration: 18 General Appearance Healthy appearing adult female in no acute distress. Alert and oriented; 

answers questions appropriately.  

Skin Skin is normal color for ethnicity, warm, dry, clean and intact. No rashes or lesions noted. HEENT Head is norm cephalic, hair evenly distributed. Neck: Supple. Full ROM. Teeth are in good repair. Cardiovascular S1, S2 with regular rate and rhythm. No extra heart sounds.  Respiratory Symmetric chest walls. Respirations regular and easy; lungs clear to auscultation bilaterally. Gastrointestinal Abdomen flat; BS active in all 4 quadrants. Abdomen soft, suprapubic tender. No hepatosplenomegaly.    Genitourinary Suprapubic tenderness noted.  Skin color normal for ethnicity.  Irritation noted at labia majora, minora, and perineum. No ulcerated lesions noted. Lymph nodes not palpable.  Vagina pink and moist without lesions.  Discharge minimal, thick, dark red, no odor.  Cervix pink without lesions. No CMT. Uterus normal size, shape, and consistency.         Musculoskeletal Full ROM seen in all 4 extremities as patient moved about the exam room. Neurological  Speech clear. Good tone. Posture erect. Balance stable; gait normal. Psychiatric Alert and oriented. Dressed in clean clothes. Maintains eye contact. Answers questions appropriately. 

Lab Tests Urinalysis – blood noted (pt. on menstrual period), but results negative for infection Urine culture testing unavailable Wet prep – inconclusive  STD testing pending for gonorrhea, chlamydia, syphilis, HIV, HSV 1 & 2, Hep B & C    Special Tests- No ordered at this time.    

Diagnosis   Differential Diagnoses :

1-Bacterial Vaginosis (N76.0) o

2- Malignant neoplasm of female genital organ, unspecified. (C57.9) 

3-Gonococcal infection, unspecified. (A54.9) Diagnosis o Urinary tract infection, site not specified. (N39.0) Candidiasis of vulva and vagina. (B37.3) secondary to presenting symptoms (Colgan & Williams, 2011) & (Hainer & Gibson, 2011).   Plan/Therapeutics •

Plan:   o Medication : Terconazole cream 1 vaginal application QHS for 7 days for Vulvovaginal Candidiasis;   Sulfamethoxazole/TMP DS 1 tablet PO twice daily for 3 days for UTI (Woo & Wynne, 2012) o Education –  Medications prescribed:UTI and Candidiasis symptoms, causes, risks, treatment, prevention. Reasons to seek emergent care, including N/V, fever, or back pain.    STD risks and preventions.   Ulcer prevention, including taking Protonix as prescribed, not exceeding the recommended dose limit of NSAIDs, and not taking NSAIDs on an empty stomach.   o Follow-up –   Pt will be contacted with results of STD studies.    Return to clinic when finished the period for perform pap-smear or if symptoms do not resolve with prescribed TX.     

                         References 

Colgan, R. & Williams, M. (2011). Diagnosis and Treatment of Acute Uncomplicated Cystitis. American Family Physician, 84(7), 771-776. Hainer, B. & Gibson, M. (2011). Vaginitis: Diagnosis and Treatment. American Family Physician, 83(7), 807-815.  Woo, T. M., & Wynne, A. L. (2012). Pharmacotherapeutics for Nurse Practitioner Prescribers (3rd ed.). Philadelphia, PA: F.A. Davis Company.

Discussion Question

Begin your discussion by sharing your problem statement and research question. Next, discuss your sampling plan. In addition, discuss your research design. Consider the following as you craft your response.

Sampling

• How will the sample be selected?
• What type of sampling method is used? Is it appropriate to the design?
• Does the sample reflect the population as identified in the problem or purpose statement?
• Is the sample size appropriate? Why or why not?
• To what population may the findings be generalized? What are the limitations in generalizability?

Research design

• What type of design will be used?
• Does the design seem to flow from the proposed research problem, theoretical framework, literature review, and hypothesis?

 

Assignment 6.1: Personality Traits-Especially Mine

Personality Traits-Especially Mine

OBJECTIVE

Identify the different personality traits and research methods

ASSIGNMENT OVERVIEW

This reaction and response assignment explores personality traits.

DELIVERABLES

A one-page (12-point font) paper

Step 1 Complete and score the Myers-Briggs personality trait test.

Human Metrics

Note: Your instructor may substitute another personality trait test.

Step 2 Compare the test results with your view of your dominant personality traits.

• Do you think the test is accurate?
• Do you see yourself differently than the test?

Step 3 Summarize what you learned.

Write a one-page summary of the results of the personality test and address whether or not you agree with them.

 

Soap Note 1 Acute Conditions (15 Points)

Pick any Acute Disease from Weeks 1-5 (see syllabus)

Soap notes will be uploaded to Moodle and put through TURN-It-In (anti-Plagiarism program)

Turn it in Score must be less than 50% or will not be accepted for credit, must be your own work and in your own words. You can resubmit, Final submission will be accepted if less than 50%. Copy paste from websites or textbooks will not be accepted or tolerated. Please see College Handbook with reference to Academic Misconduct Statement.

Late Assignment Policy

Assignments turned in late will have 1 point taken off for every day assignment is late, after 7 days assignment will get grade of 0. No exceptions 

Follow the MRU Soap Note Rubric as a guide:

Grading Rubric

Student______________________________________

This sheet is to help you understand what we are looking for, and what our margin remarks might be about on your write ups of patients. Since at all of the white-ups that you hand in are uniform, this represents what MUST be included in every write-up.

1)      Identifying Data (___5pts): The opening list of the note. It contains age, sex, race, marital status, etc. The patient complaint should be given in quotes. If the patient has more than one complaint, each complaint should be listed separately (1, 2, etc.) and each addressed in the subjective and under the appropriate number.

2)      Subjective Data (___30pts.): This is the historical part of the note. It contains the following:

a) Symptom analysis/HPI(Location, quality , quantity or severity, timing, setting, factors that make it better or worse, and associate manifestations.(10pts).

b) Review of systems of associated systems, reporting all pertinent positives and negatives (10pts).

c) Any PMH, family hx, social hx, allergies, medications related to the complaint/problem (10pts). If more than one chief complaint, each should be written u in this manner.

3)      Objective Data(__25pt.): Vital signs need to be present. Height and Weight should be included where appropriate.

a)      Appropriate systems are examined, listed in the note and consistent with those identified in 2b.(10pts).

b)      Pertinent positives and negatives must be documented for each relevant system.

c)        Any abnormalities must be fully described. Measure and record sizes of things (likes moles, scars). Avoid using “ok”, “clear”, “within normal limits”, positive/ negative, and normal/abnormal to describe things. (5pts).

4)      Assessment (___10pts.): Diagnoses should be clearly listed and worded appropriately.

5)      Plan (___15pts.): Be sure to include any teaching, health maintenance and counseling along with the pharmacological and non-pharmacological measures. If you have more than one diagnosis, it is helpful to have this section divided into separate numbered sections.

6)      Subjective/ Objective, Assessment and Management and Consistent (___10pts.): Does the note support the appropriate differential diagnosis process? Is there evidence that you know what systems and what symptoms go with which complaints? The assessment/diagnoses should be consistent with the subjective section and then the assessment and plan. The management should be consistent with the assessment/ diagnoses identified.

7)      Clarity of the Write-up(___5pts.): Is it literate, organized and complete?

• Soap Note 1 Acute ConditionsAssignment