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

Nursing Assignment Help 2025

Assignment: Evidence-Based Project, Part 3: Critical Appraisal of Research 2025

PLEASE FOLLOW THE INSTRUCTIONS AS INDICATED BELOW: 1). ZERO (0) PLAGIARISM 2). ATLEAST 5 REFERENCES, NO MORE THAN 5 YEARS 3). PLEASE SEE THE FOLLOWING ATTACHMENTS: RUBRIC DETAILS, CRITICAL APPRAISAL TOOLTEMPLATE, ONE ARTICLE Please carefully review the grading rubric, especially the first column that says, “Excellent”, and please include each component in the assignment requirements. 4). Please Include Introduction, purpose statement, conclusion, and reference page, (APA formatting) 5). PLEASE STICK TO THE NUMBER OF PAGES REQUIRED FOR THE ASSIGNMENT. Thank you. ASSIGNMENT: Realtors rely on detailed property appraisals—conducted using appraisal tools—to assign market values to houses and other properties. These values are then presented to buyers and sellers to set prices and initiate offers. Research appraisal is not that different. The critical appraisal process utilizes formal appraisal tools to assess the results of research to determine value to the context at hand. Evidence-based practitioners often present these findings to make the case for specific courses of action. In this Assignment, you will use an appraisal tool to conduct a critical appraisal of published research. You will then present the results of your efforts. To Prepare: Reflect on the four peer-reviewed articles you selected in Module 2 and the four systematic reviews (or other filtered high- level evidence) you selected in Module 3. Reflect on the four peer-reviewed articles you selected in Module 2 and analyzed in Module 3. Review and download the Critical Appraisal Tool Worksheet Template provided in the Resources. The Assignment (Evidence-Based Project) Part 3A: Critical Appraisal of Research Conduct a critical appraisal of the four peer-reviewed articles you selected by completing the Evaluation Table within the Critical Appraisal Tool Worksheet Template. Choose a total of four peer-reviewed articles that you selected related to your clinical topic of interest in Module 2 and Module 3. Note : You can choose any combination of articles from Modules 2 and 3 for your Critical Appraisal. For example, you may choose two unfiltered research articles from Module 2 and two filtered research articles (systematic reviews) from Module 3 or one article from Module 2 and three articles from Module 3. You can choose any combination of articles from the prior Module Assignments as long as both modules and types of studies are represented. Part 3B: Critical Appraisal of Research Based on your appraisal, in a 1-2-page critical appraisal, suggest a best practice that emerges from the research you reviewed. Briefly explain the best practice, justifying your proposal with APA citations of the research.

Nursing Assignment Help 2025

Basic Windshield Survey – Rural 2025

Basic Windshield Survey – Rural Enter Sentinel Town® via the link to begin your virtual experience by taking a tour by car of Sentinel Town®. Since this is your first tour, select the slowest speed and stay in the car the entire time at least once before getting out of the car. As you take the tour, write down your observations, specifically those that align with the following demographics and/or subsystems listed in the left-hand column of the rubric. Describe the characteristics of the people you see in Sentinel Town®. What are the race/ethnicity distribution, age ranges, and gender mix? Are there signs of poverty or wealth? What are they? Who do you see on the streets? Parent with child, teens, couples, disabled persons? Are there homeless persons, beggars, etc.? Is there anyone in the city you would not expect to see? Are there dogs on or off leash? Are there other animals? Are there churches and other formal religious buildings? What are their denominations? Compile your observations addressing each item listed in the first column of the rubric. You are encouraged to add other relevant observations that may not be listed in the first column. Select a target population of interest and discuss relevant demographic data and health status indicators for this population group. Identify major health concerns for this target population. Include a discussion of major health concerns in relation to a global health issue. Reading and Resources Harkness & DeMarco (2016) Read Chapters 1 & 2 Read all Sentinel City information available at the top of the course homepage. Visit QSEN : Quality and Safety Education for Nurses Read the Report: The Future of Nursing: Leading Change, Advancing Health Read the Report: The Future of Public Health Review Final Project Requirements Watch the Henry Street Settlement: 120 Years in 4 Minutes Video View this 9 minute video entitled Community Assessment Windshield Survey , to help you see what types of things to look for when you conduct a windshield survey in the Sentinel City simulation Additional Instructions: All submissions should have a title page and reference page. Utilize a minimum of two scholarly resources. Adhere to grammar, spelling and punctuation criteria. Adhere to APA compliance guidelines. Adhere to the chosen Submission Option for Delivery of Activity guidelines. Submission Option Instruction Paper 4 to 6-page paper. Include title and reference pages. Note: Title and reference pages/slides do not count towards the count requirements. Attachments area Preview YouTube video Henry Street Settlement: 120 Years in 4 Minutes Preview YouTube video Community Assessment Windshield Survey Community Assessment Windshield Survey ReplyReply allForward

Nursing Assignment Help 2025

Details: View the scenario called “Critical Decision Making for Providers 2025

Details: View the scenario called “Critical Decision Making for Providers” found in the Allied Health Community media ( http://lc.gcumedia.com/hlt307v/allied-health-community/allied-health-community-v1.1.html ) In a 800-1,200 word paper, describe the scenario involving Mike, the lab technician, and answer the following questions: 1. What were the consequences of a failure to report? 2. What impact did his decision have on patient safety, on the risk for litigation, on the organization’s quality metrics, and on the workload of other hospital departments? 3. As Mike’s manager, what will you do to address the issue with him and ensure other staff members do not repeat the same mistakes? Prepare this assignment according to the APA guidelines In addition to your textbook, “ The Interprofessional Health Care Team: Leadership and Development”. A minimum of FOUR academic references from credible sources are required for this assignment.

Nursing Assignment Help 2025

Details: Collaborative Decision Making Through Shared Governance 2025

Details: Collaborative Decision Making Through Shared Governance Attend a committee meeting in your health care organization Attend a committee meeting in your health care organization. If you are not currently employed in a health care setting, you may elect to attend a committee meeting at another company, a community center, a local school, local chamber of commerce or other professional organization. Observe the interactions between committee members and the process used by the committee to arrive at decisions. In 500-750 words, describe the function of the committee and the roles of those in attendance. Describe your observations of the interactions between members of the committee and determine whether the process used to arrive at decisions is a form of shared governance. Prepare this assignment according to the APA guidelines In addition to your textbook, “ The Interprofessional Health Care Team: Leadership and Development”. A minimum of FOUR academic references from credible sources are required for this assignment.

Nursing Assignment Help 2025