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.

 

Journaling provides a valuable tool for recording, reflecting on, and reviewing your learning. This approach provides an opportunity for you to “connect the dots” and observe the relationships between and among activities, interactions, and outcomes.

Unlike a personal journal of thoughts and feelings, this leadership journal is a record of your activities, assessments, and learning related to this academic experience.

Journal entries should include a record of the number of hours spent with your nurse leader each week.

Write a journal entry of 750-1,500 words on the subject of provision, including the following:

1. Practicum Activities Reflection: Provide observations and thoughts on the activities in your practicum 
2. Application of Leadership: Describe how your nurse leader preceptor influences the work environment. Consider how influence protects and values others in the work environment.
3. Practicum Project Preparation: Describe any potential or actual barriers you have encountered as you prepared for project implementation. If you have not encountered any, what could present a barrier in the future?
4. Leadership Video Reflection: Reflect on at least two things you learned from the “Servant Leadership – Issue of Headship” video.

 

 

Required Resources
Read/review the following resources for this activity:

• Textbook: Chapter 8, 9, 10
• Lesson
• Minimum of 6 scholarly sources (at least 2 for Judaism, 2 for Christianity, & 2 for Islam)
  • Please review criteria for scholarly sources. 

Instructions
In a short essay, complete the following:

• Explain the historical relationship between Judaism, Christianity, and Islam. What are their geographical connections? What are their historical timelines?
• Analyze the historical relationship between Judaism, Christianity, and Islam in order to make an argument about the similarities and differences between the three religions. Select one main example from the following list on which to focus your comparison: the nature of God, the nature of Jesus, Holy Books, or Salvation. Your analysis should span multiple paragraphs and utilize specific examples.
• Conclude by examining the current relationship between Judaism, Christianity, and Islam today. How has globalization influenced or affected the current relationship?

Your paper should include an introduction and thesis that clearly states your central claim, thoughtful examples and analysis in your body paragraphs, and a conclusion to finalize your thoughts.

Writing Requirements (APA format)

• Length: 1200-1400 words (not including title page or references page)
• 1-inch margins
• Double spaced
• 12-point Times New Roman font
• Title page
• References page (minimum of 6 scholarly sources)

Grading
This activity will be graded based on the Written Assignment Grading Rubric.

Weekly Objectives (WO)
WO4.1, 4.2, 6.11-6.13, 7.3

Resource: 

 

Molloy, M. (2013). Experiencing the world’s religions (6th ed.). New York City, NY: McGraw-Hill Companies, Inc.

Sally, a nurse for community mental health is caring for 3 clients today. First, she meets Sam. Sam has been admitted to a psychiatric unit with a diagnosis of psychosis and schizophrenia. Sally provides Sam with appropriate interventions to help stabilize his condition, monitors his compliance with medication and conducts therapy sessions. Explain in 200 words.

1. Sally is using what level of prevention according to the Neuman Systems Model?

2. Give a few examples of  nursing actions using Tertiary preventions as interventions. 

PermalinkReply

       

Assignment Instructions

Lisa Anderson, a 22 y.o., Caucasian single parent, is referred for genetic counseling by her pediatric Nurse Practitioner. She has a 3-year-old boy with developmental delay and small joint hyperextensibility. The pediatric Nurse Practitioner has diagnosed fragile X-associated mental retardation. She is currently pregnant with her second child at 14 weeks of gestation. The family history is unremarkable.

Please use the following headings/subheadings as a guide to draft your paper:

1. Introduction (including a brief purpose statement)
2. Identify the genetic mutation responsible for fragile X-associated mental retardation.
3. Describe and discuss how it causes the clinical syndrome of developmental delay, joint hyperextensibility, large testes, and facial abnormalities.
4. Identify which parent is the probable carrier of the genetic mutation?
5. Explain why this parent and the grandparents are phenotypically unaffected.
6. Discuss the likelihood that the unborn child will be affected?
7. Conclusion

In regards to APA format, please use the following as a guide:

• Include a cover page and running head (this is not part of the 4-5 page limit)
• Include transitions in your paper (i.e. headings or subheadings)
• Use in-text references throughout the paper
• Use double space, 12 point Times New Roman font
• Spelling, grammar, and organization are appropriate
• Include a reference list (this is not part of the 4-5 page limit)
• Attempt to use primary sources only. That said, you may cite reliable electronic sources (i.e. ANA)