Evidence base practice – 2025 To Prepare Review the Resources and identify a clinical issue of interest that can form the basis of a

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Evidence base practice – 2025

To Prepare:

  • Review the Resources and identify a clinical issue of interest that can form the basis of a clinical inquiry.
  • Based on the clinical issue of interest and using keywords related to the clinical issue of interest, search at least four different databases in the Walden Library to identify at least four relevant peer-reviewed articles related to your clinical issue of interest. You should not be using systematic reviews for this assignment, select original research articles.
  • Review the results of your peer-reviewed research and reflect on the process of using an unfiltered database to search for peer-reviewed research.
  • Reflect on the types of research methodologies contained in the four relevant peer-reviewed articles you selected.

Part 1: An Introduction to Clinical Inquiry

Create a 4- to 5-slide PowerPoint presentation in which you do the following:

  • Identify and briefly describe your chosen clinical issue of interest. This clinical issue will remain the same for the entire course and will be the basis for the development of your PICOT question
  • Describe how you used keywords to search on your chosen clinical issue of interest.
  • Identify the four research databases that you used to conduct your search for the peer-reviewed articles you selected.
  • Provide APA citations of the four peer-reviewed articles you selected.

Part 2: Identifying Research Methodologies

After reading each of the four peer-reviewed articles you selected, use the Matrix Worksheet template to analyze the methodologies applied in each of the four peer-reviewed articles. Your analysis should include the following:

  • The full citation of each peer-reviewed article in APA format.
  • A brief (1-paragraph) statement explaining why you chose this peer-reviewed article and/or how it relates to your clinical issue of interest, including a brief explanation of the ethics of research related to your clinical issue of interest.
  • A brief (1-2 paragraph) description of the aims of the research of each peer-reviewed article.
  • A brief (1-2 paragraph) description of the research methodology used. Be sure to identify if the methodology used was qualitative, quantitative, or a mixed-methods approach. Be specific.
  • A brief (1- to 2-paragraph) description of the strengths of each of the research methodologies used, including reliability and validity of how the methodology was applied in each of the peer-reviewed articles you selected.
  •  
  • Matrix Worksheet Template 
  • Use this document to complete Part 2 of the Module 2 Assessment, Evidence-Based Project, Part 1: An Introduction to Clinical Inquiry and Part 2: Research Methodologies
  • Full citation of selected article Article #1 Article #2 Article #3 Article #4
  • Why you chose this article and/or how it relates to the clinical issue of interest (include a brief explanation of the ethics of research related to your clinical issue of interest)
  • Brief description of the aims of the research of each peer-reviewed article
  • Brief description of the research methodology used Be sure to identify if the methodology used was qualitative, quantitative, or a mixed-methods approach. Be specific.
  • A brief description of the strengths of each of the research methodologies used, including reliability and validity of how the methodology was applied in each of the peer-reviewed articles you selected.
  • General Notes/Comments

Genetic Mutation – 2025 Assignment Instructions Lisa Anderson a 22 y o Caucasian single parent is referred for genetic counseling by her pediatric Nurse Practitioner

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Genetic Mutation – 2025

       

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)

week 1 6050 – 2025 Discussion Presidential Agendas Regardless of political affiliation every citizen has a stake in healthcare

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week 1 6050 – 2025

Discussion: Presidential Agendas

Regardless of political affiliation, every citizen has a stake in healthcare policy decisions. Hence, it is little wonder why healthcare items become such high-profile components of presidential agendas. It is also little wonder why they become such hotly debated agenda items.

Consider a topic that rises to the presidential level. How did each of the presidents (Trump, Obama, and Bush) handle the problem? What would you do differently?

To Prepare:

  • Review the Resources and reflect on the importance of agenda setting.
  • Consider how federal agendas promote healthcare issues and how these healthcare issues become agenda priorities.
By Day 3 of Week 1

Post your response to the discussion question: Consider a topic that rises to the presidential level. How did each of the presidents (Trump, Obama, and Bush) handle the problem? What would you do differently?

By Day 6 of Week 1

Respond to at least two of your colleagues* on two different days by expanding on their response and providing an example that supports their explanation or respectfully challenging their explanation and providing an example.

Learning Resources

Note: To access this week’s required library resources, please click on the link to the Course Readings List, found in the Course Materials section of your Syllabus.

Required Readings

Milstead, J. A., & Short, N. M. (2019). Health policy and politics: A nurse’s guide (6th ed.). Burlington, MA: Jones & Bartlett Learning.
Chapter 1, “Informing Public Policy: An Important Role for Registered Nurses” (pp. 11–13 only)
Chapter 2, “Agenda Setting: What Rises to a Policymaker’s Attention?” (pp. 17–36)
Chapter 10, “Overview: The Economics and Finance of Health Care” (pp. 171–180)
Chapter 12, “An Insider’s Guide to Engaging in Policy Activities”“Creating a Fact Sheet” (pp. 217-221)

DeMarco, R., & Tufts, K. A. (2014). The mechanics of writing a policy brief. Nursing Outlook, 62(3), 219–224. doi:10.1016/j.outlook.2014.04.002
Note: You will access this article from the Walden Library databases.

Kingdon, J. W. (2001). A model of agenda-setting, with applications. Law Review, M.S.U.-D.C.L., 2(331).
Note: You will access this article from the Walden Library databases.

Lamb, G., Newhouse, R., Beverly, C., Toney, D. A., Cropley, S., Weaver, C. A., Kurtzman, E., … Peterson, C. (2015). Policy agenda for nurse-led care coordination. Nursing Outlook, 63(4), 521–530. doi:10.1016/j.outlook.2015.06.003
Note: You will access this article from the Walden Library databases.

O’Rourke, N. C., Crawford, S. L., Morris, N. S., & Pulcini, J. (2017). Political efficacy and participation of nurse practitioners. Policy, Politics, and Nursing Practice, 18(3), 135–148. doi:10.1177/1527154417728514
Note: You will access this article from the Walden Library databases.

Institute of Medicine (US) Committee on Enhancing Environmental Health Content in Nursing Practice, Pope, A. M., Snyder, M. A., & Mood, L. H. (Eds.). (n.d.). Nursing health, & environment: Strengthening the relationship to improve the public’s health. Retrieved September 20, 2018.
Note: You will access this article from the Walden Library databases.

USA.gov. (n.d.). A-Z index of U.S. government departments and agencies. Retrieved September 20, 2018, from https://www.usa.gov/federal-agencies/a 

USA.gov. (n.d.). Executive departments. Retrieved September 20, 2018, from https://www.usa.gov/executive-departments

The White House. (n.d.). The cabinet. Retrieved September 20, 2018, from https://www.whitehouse.gov/the-trump-administration/the-cabinet/

Document: Agenda Comparison Grid Template (Word document)

informatics – 2025 In the Chapter 7 summary Staggers and Nelson state In a way all of us are already informatics nurses Reflect

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informatics – 2025

  • In the Chapter 7 summary, Staggers and Nelson state, “In a way all of us are already informatics nurses.” Reflect on this summary statement and describe a scenario from your clinical experience where you manipulated data, information, and knowledge to make a wise decision. Focus specifically on the key concepts of data, information, knowledge and wisdom.  
  • What do you believe are the advantages and disadvantages of having a single shared consensus-driven model of terminology use? How can a single agreed model of terminology use (with linkages to a single terminology) help to integrate knowledge into routine clinical practice?
  • Hospital C is looking to implement an EHR. It has been suggested that a NIS be hired. This position does not involve direct patient care and the administration is struggling with how to justify the position. How can this position be justified?

NR631 week 2 IP2 – 2025 Week 2 Project Scope and Charter R631 W2 Project Scope and Charter Guidelines and

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NR631 week 2 IP2 – 2025

 

Week 2: Project Scope and Charter

R631 W2 Project Scope and Charter Guidelines and Rubric

NR631 W2 Project Charter Appendix

NR631 W2 Scope Statement Appendix

Purpose

This assignment is designed to help students lay the groundwork for their project plans with the help of mentors and professors. The mentor becomes a team member for the project that the student will manage. The student will identify the stakeholders, the project priority, how the measurable goals will be met for a successful project, and who will receive the report of the results of the project. The scope document describes the parameters of the project, including what can and cannot be accomplished and the measurable objectives and outcome measures. The project charter describes and defines the project. When the sponsor signs off on the project, it becomes the document that authorizes the project.

Week 2, you will complete the project scope and charter. Based on the information from the mentor and professor, each student finalizes and completes the project charter and scope documents or statements. The project scope must be approved by your practicum organization. Your mentor should help you obtain approval. Project approval must be received prior to submitting these documents. Appendices are provided for both of these documents above.

Course Outcomes

This assignment enables the student to meet the following Course Outcomes (COs):

CO 1: Apply leadership skills concepts of project management as a nurse executive in an organizational setting to develop, implement and evaluate successful project plans. (PO 4,5)

CO 2: Using current knowledge, standards of practice, and research from evidence-based literature, synthesize a foundation for the nurse executive role. (PO 3,4)

Due Date: Sunday at 11:59 p.m. MT at the end of Week 2

Students are given the opportunity to request an extension on assignments for emergent situations. Supporting documentation must be submitted to the assigned faculty. If the student’s request is not approved, the assignment is graded and a late penalty is applied as follows:

If the student’s request is approved, the student will be informed of the revised due date. Should the student fail to meet the revised due date, the assignment is graded and a late penalty is applied as follows:

Total Points Possible: 100

Requirements

  1. Complete the Project Scope document, including signatures of approval.
  2. Complete the Project Charter document.
  3. Documents are attached as appendices to a professional, scholarly paper following the guidelines for writing professional papers found in the Resources tab.
  4. Grammar, spelling, punctuation, references, and citations must be consistent with formal academic writing and APA format as expressed in the sixth edition of the APA manual.

Preparing the paper

  1. All aspects of the Project Scope document must be completed, including signatures.
  2. All aspects of the Project Chart document must be completed.
  3. Ideas, references, and information from professional sources must be cited correctly using the sixth edition of the APA manual.
  4. Grammar, spelling, punctuation, references, and citations must be consistent with formal academic writing.

Healthcare Policy – 2025 In this assignment you will assess the impact of health legislation on nursing

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Healthcare Policy – 2025

In this assignment, you will assess the impact of health legislation on nursing practice and communicate your analysis to your peers. GovTrack.us provides a list of federal health bills that are currently in process in Congressional Committees.

  1. Please review the infographic as way to guide you in getting started with your assignment: Developing an Assignment with Integrity (Links to an external site.)
  2. View a short tutorial with tips for completing this assignment: Healthcare Policy Assignment Tutorial (Links to an external site.)
  3.  (Links to an external site.)This assignment will be in the format of a PowerPoint presentation (Bullet points may be used).
  4. You are educating your peers through this presentation regarding a federal bill you believe may be of interest to nurses.
  5. Go to https://www.govtrack.us/congress/bills/subjects/health/6130 (Links to an external site.)
  6. Choose a health-related federal bill of interest. Read through the bill and develop a summary in your own words. Include the bill number and name.
  7. Here is a link to our U.S. legislative process (bill to law) for review, if needed: https://www.congress.gov/legislative-process (Links to an external site.)
  8. For those not familiar with the development of a PowerPoint slideshow, the following link to the Microsoft Office 365 Training (Links to an external site.) may be helpful.
  9. Include the following information in your presentation
    • Title slide (Your name, NR451, session, Healthcare Policy assignment)
    • Bill name and number (indicate either H.B. or S.B.)
    • Bill summary (in your own words)
    • Address how this bill might impact professional nursing practice standards if passed? If not passed?
    • How might the bill impact your own nursing practice?
    • How might you communicate your concerns about or support for this bill based on nursing practice, standards, or patient outcomes?
    • How might this bill impact your community?
    • References slide to include the Bill source in APA format.
    • No more than 12 slides

Template

There is no required form or template for this assignment. Please use PowerPoint best practices throughout your presentation.

Cite all sources on the appropriate slides with (author, year) as well as on the Reference slide.

Advanced Health Assessment. SOAP – 2025 Week 5 Assessment of Head Neck Eyes Ears Nose and Throat Emily age 15 is brought to your

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Advanced Health Assessment. SOAP – 2025

  

Week 5: Assessment of Head, Neck, Eyes, Ears, Nose, and Throat

Emily, age 15, is brought to your clinic complaining of chills, aches, and a sore throat. Without any testing, consider all of the possible diagnoses. It could be a cold, the flu, bronchitis, or even something more serious, such as meningitis or mononucleosis. Assessing the actual cause will involve much more than simple visual inspection. Some conditions are so subtle that they require the use of special instruments and tests in addition to a trained eye and ear.

This week, you will explore how to assess the head, neck, eyes, ears, nose, and throat. Whether dealing with a detached retina, sinusitis, meningitis, or even cough, advanced practice nurses need to know the proper assessment techniques in order to form accurate diagnoses.

Ball, J. W., Dains, J. E., Flynn, J. A., Solomon, B. S., & Stewart, R. W. (2019). Seidel’s guide to physical examination: An interprofessional approach (9th ed.). St. Louis, MO: Elsevier Mosby.

  • Chapter 11, “Head and Neck”

         This chapter reviews the anatomy and physiology of the head and neck. The      authors also describe the procedures for conducting a physical examination      of the head and neck.

  • Chapter 12, “Eyes”

         In this chapter, the authors describe the anatomy and function of the      eyes. In addition, the authors explain the steps involved in conducting a      physical examination of the eyes.

  • Chapter 13, “Ears, Nose, and Throat”

         The authors of this chapter detail the proper procedures for conducting a      physical exam of the ears, nose, and throat. The chapter also provides      pictures and descriptions of common abnormalities in the ears, nose, and      throat.

Dains, J. E., Baumann, L. C., & Scheibel, P. (2019). Advanced health assessment and clinical diagnosis in primary care (6th ed.). St. Louis, MO: Elsevier Mosby.

Credit Line: Advanced Health Assessment and Clinical Diagnosis in Primary Care, 6th Edition by Dains, J.E., Baumann, L. C., & Scheibel, P. Copyright 2019 by Mosby. Reprinted by permission of Mosby via the Copyright Clearance Center.

 

Chapter 15, “Earache”
This chapter covers the main questions that need to be asked about the patient’s condition prior to the physical examination as well as how these questions lead to a focused physical examination.

Chapter 21, “Hoarseness”
This chapter focuses on the most common causes of hoarseness. It provides strategies for evaluating the patient, both through questions and through physical exams.

Chapter 25, “Nasal Symptoms and Sinus Congestion”

In this chapter, the authors highlight the key questions to ask about the patients symptoms, the key parts of the physical examination, and potential laboratory work that might be needed to provide an accurate diagnosis of nasal and sinus conditions.

Chapter 30, “Red Eye”

The focus of this chapter is on how to determine the cause of red eyes in a patient, including key symptoms to consider and possible diagnoses.

Chapter 32, “Sore Throat”

A sore throat is one most common concerns patients describe. This chapter includes questions to ask when taking the patient’s history, things to look for while conducting the physical exam, and possible causes for the sore throat.

Chapter 38, “Vision Loss”
This chapter highlights the causes of vision loss and how the causes of the condition can be diagnosed.

Note: Download the six documents (Student Checklists and Key Points) below, and use them as you practice conducting assessments of the head, neck, eyes, ears, nose, and throat.

Ball, J. W., Dains, J. E., Flynn, J. A., Solomon, B. S., & Stewart, R. W. (2019). Head and neck: Student checklist. In Seidel’s guide to physical examination: An interprofessional approach (9th ed.). St. Louis, MO: Elsevier Mosby.

Credit Line: Seidel’s Guide to Physical Examination, 9th Edition by Ball, J. W., Dains, J. E., Flynn, J. A., Solomon, B. S., & Stewart, R. W. Copyright 2019 by Elsevier Health Sciences. Reprinted by permission of Elsevier Health Sciences via the Copyright Clearance Center.

Ball, J. W., Dains, J. E., Flynn, J. A., & Solomon, B. S., & Stewart, R. W. (2019). Head and neck: Key points. In Seidel’s guide to physical examination: An interprofessional approach (9th ed.). St. Louis, MO: Elsevier Mosby.

Credit Line: Seidel’s Guide to Physical Examination, 9th Edition by Ball, J. W., Dains, J. E., Flynn, J. A., Solomon, B. S., & Stewart, R. W. Copyright 2019 by Elsevier Health Sciences. Reprinted by permission of Elsevier Health Sciences via the Copyright Clearance Center.

Ball, J. W., Dains, J. E., Flynn, J. A., Solomon, B. S., & Stewart, R. W. (2019). Eyes: Student checklist. In Seidel’s guide to physical examination: An interprofessional approach (9th ed.). St. Louis, MO: Elsevier Mosby.

Credit Line: Seidel’s Guide to Physical Examination, 9th Edition by Ball, J. W., Dains, J. E., Flynn, J. A., Solomon, B. S., & Stewart, R. W. Copyright 2019 by Elsevier Health Sciences. Reprinted by permission of Elsevier Health Sciences via the Copyright Clearance Center.

Ball, J. W., Dains, J. E., Flynn, J. A., Solomon, B. S., & Stewart, R. W. (2019). Eyes: Key points. In Seidel’s guide to physical examination: An interprofessional approach (9th ed.). St. Louis, MO: Elsevier Mosby.

Credit Line: Seidel’s Guide to Physical Examination, 9th Edition by Ball, J. W., Dains, J. E., Flynn, J. A., Solomon, B. S., & Stewart, R. W. Copyright 2019 by Elsevier Health Sciences. Reprinted by permission of Elsevier Health Sciences via the Copyright Clearance Center.

Ball, J. W., Dains, J. E., Flynn, J. A., Solomon, B. S., & Stewart, R. W. (2019). Ears, nose, and throat: Student checklist. In Seidel’s guide to physical examination: An interprofessional approach (9th ed.). St. Louis, MO: Elsevier Mosby.

Credit Line: Seidel’s Guide to Physical Examination, 9th Edition by Ball, J. W., Dains, J. E., Flynn, J. A., Solomon, B. S., & Stewart, R. W. Copyright 2019 by Elsevier Health Sciences. Reprinted by permission of Elsevier Health Sciences via the Copyright Clearance Center.

Ball, J. W., Dains, J. E., Flynn, J. A., Solomon, B. S., & Stewart, R. W. (2019). Ears, nose, and throat: Key points. In Seidel’s guide to physical examination: An interprofessional approach (9th ed.). St. Louis, MO: Elsevier Mosby.

Credit Line: Seidel’s Guide to Physical Examination, 9th Edition by Ball, J. W., Dains, J. E., Flynn, J. A., Solomon, B. S., & Stewart, R. W. Copyright 2019 by Elsevier Health Sciences. Reprinted by permission of Elsevier Health Sciences via the Copyright Clearance Center.

Colyar, M. R. (2015). Advanced practice nursing procedures. Philadelphia, PA: F. A. Davis.

Credit Line: Advanced practice nursing procedures, 1st Edition by Colyar, M. R. Copyright 2015 by F. A. Davis Company. Reprinted by permission of F. A. Davis Company via the Copyright Clearance Center.

Sullivan, D. D. (2019). Guide to clinical documentation (3rd ed.). Philadelphia, PA: F. A. Davis.

  • Chapter 2, “The Comprehensive History and      Physical Exam” (Previously read in Weeks 1, 3, 4, and 5)

Bedell, H. E., & Stevenson, S. B. (2013). Eye movement testing in clinical examination. Vision Research 90, 32–37. doi:10.1016/j.visres.2013.02.001. Retrieved from https://www.sciencedirect.com/science/article/pii/S0042698913000217 

Rubin, G. S. (2013). Measuring reading performance. Vision Research, 90, 43–51. doi:10.1016/j.visres.2013.02.015. Retrieved from http://www.sciencedirect.com/science/article/pii/S0042698913000436  

Harmes, K. M., Blackwood, R. A., Burrows, H. L., Cooke, J. M., Harrison, R. V., & Passamani, P. P. (2013). Otitis media: Diagnosis and treatment. American Family Physicians, 88(7), 435–440.

Otolaryngology Houston. (2014). Imaging of maxillary sinusitis (X-ray, CT, and MRI). Retrieved from http://www.ghorayeb.com/ImagingMaxillarySinusitis.html

This website provides medical images of sinusitis, including X-rays, CT scans, and MRIs (magnetic resonance imaging).

Focused Ear Exam

CASE STUDY: 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 2 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.

Use the Episodic/Focused SOAP Template and create an episodic/focused note about the patient in the case study to which you were assigned using the episodic/focused note template provided in the 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.

Week 6 Discussion Forum Pathophysiology – 2025 Please refer to Chapter 28 and then answer all of the questions that follow the case study

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Week 6 Discussion Forum Pathophysiology – 2025

Please refer to Chapter 28 and then answer all of the questions that follow the case study:

J. S. is 23 years old. He was brought to the emergency department after an auto accident. He suffered a concussion and a deep laceration of his right thigh. He lost about 4 units of blood prior to effective control of bleeding and closure of the wound. Fluid resuscitation is initiated, and a urinary catheter is inserted post operation to monitor his urine output. However, he continues to have significant oozing from his sutured wound.

His 24-hour urine volume is 350 ml with a high urine osmolality and low urine sodium. A coagulation screen results indicate the following: platelet count 250,000, bleeding time and a PTT time are both extended. 

  1. What type of renal failure is J. S. developing? Why is this type of renal failure developing?
  2. If J. S. does not receive adequate treatment, what further condition may he develop? Why? What is the best treatment option to prevent this from occurring?
  3. What other laboratory data beside urine output should be collected to evaluate J. S.’s renal function?
  4. If J. S.’s renal function continues to be diminished without any improvement, what could be the subsequent stages of his renal disorder?

Cite specific areas from your readings and research to support your ideas. 
I will provide the pages of the chapter 28 for this assignment.
The reference for this book is 

Reference:  Banasik J. L. & Copstead, L. C. (2019).Pathophysiology (6th ed.). Elsevier, Inc.

also use outside sources as well please all in 7th edition format 

child development – 2025 Assignment Based on what you have learned in this week s readings and additional resources create a PowerPoint presentation

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child development – 2025

 

Assignment:

Based on what you have learned in this week’s readings and additional resources, create a PowerPoint presentation or Prezi that addresses each of the following points/questions.

Be sure to completely answer all of the prompts for each bullet point. Use clear headings that allow your professor to know which bullet you are addressing on the slides in your presentation. Support your content with at least five (5) citations throughout your presentation. Make sure to reference the citations using the APA writing style for the presentation. Include a reference slide at the end. Follow best practices for PowerPoint and Prezi presentations related to test size, color, images, effects, wordiness, and multimedia enhancements.

  1. Title slide (1 slide)
  2. Discuss historical views of childhood and the modern study of child development (5-7 slides)
  3. Describe developmental processes, periods, and issues (5-7 slides)
  4. Theories of Child Development (5-7 slides)
  5. Describe the challenges in Child Development research (3-5 slides)
  6. References (1 slide)

Read

Soap Note Assigment – 2025 Soap Nota Assignment Please Follow the Rubrics Family Medicine 16 68 year old male with skin lesion User

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Soap Note Assigment – 2025

Soap Nota Assignment 

Please Follow the Rubrics.

Family Medicine 16: 68-year-old male with skin lesion

User: Beatriz Duque

Email: [email protected] Date: September 14, 2020 3:00AM

Learning Objectives

The student should be able to:

Describe skin lesions with accuracy.

Define terms that describe the morphology, shape, and pattern of skin lesions.

Formulate the treatment principles of topical corticosteroid and local and systemic antifungal agents.

Apply the ABCDE criteria for the evaluation of hyperpigmented lesions as possible melanoma.

Describe common biopsy procedures, including shave biopsy, punch biopsy, and incisional and excisional biopsies.

Discuss the treatment modalities for squamous cell carcinoma.

Describe the importance and methods of prevention of skin cancers.

Develop initial workup and management of benign prostatic hyperplasia.

Knowledge

Primary and Secondary Skin Lesions

Primary skin lesions are uncomplicated lesions that represent initial pathologic change, uninfluenced by secondary alterations such as infection, trauma, or therapy.

Secondary skin lesions are changes that occur as consequences of progression of the disease, scratching, or infection of the primary lesions.

Primary Skin Lesions

Macule: A macule is a change in the color of the skin. It is flat, and if you were to close your eyes and run your fingers over the surface of a purely macular lesion, you could not detect it. It is less than 1 cm in diameter. Some authors use 5 mm for size criterion. Sometimes “macule” is used for flat lesion of any size.

Patch: A patch is a macule greater than 1 cm in diameter.

Papule: A papule is a solid raised lesion that has distinct borders and is less than 1 cm in diameter.

Plaque: A plaque is a solid, raised, flat-topped lesion greater than 1 cm in diameter. It is analogous to the geological formation, the plateau.

Nodule: A nodule is a raised solid lesion and may be in the epidermis, dermis or subcutaneous tissue.

Tumor: A tumor is a solid mass of the skin or subcutaneous tissue; it is larger than a nodule.

Vesicle: A vesicle is a raised lesion less than 1 cm in diameter and is filled with clear fluid.

Bulla: A bulla is a circumscribed fluid filled lesion that is greater than 1 cm in diameter.

Pustule: A pustule is a circumscribed elevated lesion that contains pus.

Wheal: A wheal is an area of elevated edema in the upper epidermis.

Complete list of primary and secondary skin lesions with images.

Skin Cancer Screening Recommendations

The annual skin cancer screening by full body skin examination by health care provider is an I recommendation by USPSTF. I recommendation means that current evidence is insufficient to assess the balance of benefits and harms of a primary care clinician performing a whole body skin examination or a patient doing a skin self-examination for the early detection of skin cancers.

However, the American Cancer Society recommends appropriate cancer screening by a physician, including a skin examination, during a periodic health examination. The American Academy of Dermatology promotes free skin examinations by volunteer dermatologists for the general population through the Academy’s Melanoma/Skin Cancer Screening Program. It also encourages regular self-examinations by individuals.

In the context of apparently conflicting recommendations by different organizations and when there is no sufficient evidence for the benefit or harm of certain recommendations, (like USPSTF I recommendation), the best policy may be to discuss the recommendation with patients and ask their preference. Physicians, however, should be able to discuss the possible outcomes of

the patient’s choice.

Risk For Skin Cancer

Risk factors for nonmelanoma skin cancers include:

1.  Previous skin cancer of any type gives 36% to 52% five-year risk of second skin cancer

2.  80% of lifetime sun exposure is obtained before 18 years of age (single greatest risk factor) 3. Celtic ancestry

4.  Fair complexions

5.  People who burn easily

6.  People who tan poorly and freckle

7.  Red, blonde or light brown hair

8.  Increasing age

9.  Use of coal-tar products

10.  Tobacco use

11.  Psoralen use (PUVA therapy)

12.  Male >>> female

13.  Living near equator (UV exposure)

14.  Outdoor work

15.  Chronic osteomyelitis sinus tracts

16.  Burn scars

17.  Chronic skin ulcers

18.  Xeroderma pigmentosum

19.  Human papillomavirus infection

Risk factors for melanoma skin cancer include:

1.  Previous melanoma

2.  Celtic ancestry

3.  Fair complexions

4.  People who burn easily

5.  People who tan poorly and freckle

6.  Red, blonde or light brown hair

7.  Early adulthood and later in life

8.  “Intense, intermittent exposure and blistering sunburns in childhood and adolescence are associated with increased risk”

9.  Radiation exposure

10.  Melanoma in 1st or 2nd degree relative

11.  Familial atypical mole-melanoma syndrome (FAMMS)

12.  Male > female (slight)

13.  Living near equator (UV exposure)

14.  Indoor work

15.  Higher incidence in those with more education and/or income

16.  Nonfamilial dysplastic nevi

17.  Large number of benign pigmented nevi

18.  Giant pigmented congenital nevi

19.  Nondysplastic nevi (markers for risk, not precursor lesions)

20.  Xeroderma pigmentosum

21.  Immunosuppression

22.  Previous nonmelanoma skin cancer

23.  Other malignancies

While incidence of skin cancer is higher among individuals with fair skin, patients with darker skin are also at risk for developing skin cancer and should also undergo regular screenings; conduct self examinations; and protect themselves from UV radiation.

Consent Form for Procedures

A procedure consent form aims to document adherence to one of the four principles of medical ethics: respect for autonomy. Patients can not be viewed as making their own autonomous decisions if they are not adequately informed as to the true nature of the decision. An autonomous decision to allow providers to perform a procedure requires an understanding of the the reason for the procedure, the nature of the procedure, as well as its risks, benefits, and alternatives.

Thus, a consent form should contain:

the name of the procedure the diagnosis

the risks of the procedure the benefits of the procedure

the alternative to the procedure that was proposed

Patient Education for Protection Against Sun Damage

The key to preventing a skin cancer is to stay out of the sun and not to use a sunlamp. If you are going to be in the sun, you should wear clothes made from tightly woven cloth so the sun’s rays can’t get to your skin. You should also stay in the shade when you can. Wear a wide-brimmed hat to protect your face, neck, and ears.

Remember that clouds and water won’t protect you from the sun’s rays. The sun’s rays can also reflect off water, snow, and white sand.

If you can’t stay out of the sun or wear the right kind of clothing, you should use sunscreen to protect your skin. But don’t think that you are completely safe from the sun just because you are wearing sunscreen.

Use sunscreen with a sun protection factor (SPF) of 15 or more. Put the sunscreen everywhere the sun’s rays might touch you, including your ears, the back of your neck, and bald areas on your scalp. Put more on every two to three hours and after sweating or swimming.

Patient Education on Skin Examination

What’s the best way to do a skin self-examination?

The best way is to use a full-length mirror and a hand-held mirror to check every inch of your skin.

First, you need to learn where your birthmarks, moles and blemishes are and what they usually look like. Check for anything new, such as a change in the size, texture or color of a mole, or a sore that doesn’t heal.

Look at the front and back of your body in the mirror, then raise your arms and look at the left and right sides.

Bend your elbows and look carefully at your palms and forearms, including the undersides, and your upper arms. Check the back and front of your legs.

Look between your buttocks and around your genital area.

Sit and closely examine your feet, including the bottoms of your feet and the spaces between your toes.

Look at your face, neck and scalp. You may want to use a comb or a blow dryer to move hair so that you can see better.

By checking yourself regularly, you’ll get familiar with what’s normal for you. If you find anything unusual, see your doctor. The earlier skin cancer is found, the better.

Prostatitis Syndrome Symptoms

Prostatitis syndromes tend to occur in young and middle-aged males. The symptoms of prostatitis include pain (in the perineum, lower abdomen, testicles and penis, and with ejaculation), bladder irritation, bladder outlet obstruction, and sometimes blood in the semen.

Clinical Skills

Full Skin Exam

When performing a skin exam at annual visits and/or evaluating a patient presenting with a skin lesion — have the patient change into a gown so you can perform a full skin exam.

Skin Examination

Distribution

The distribution of the skin lesions is important in diagnosing skin diseases. Many conditions have typical patterns or affect specific regions of the body. For example, psoriasis commonly affects extensor surfaces of joints, and atopic eczema impacts flexor surface of joints. Involvement of the palms and soles is seen in erythema multiforme, secondary syphilis and eczema.

Shape

Descriptions like oval, round, linear etc. can be used to describe the shape of the lesions. Annular lesions are circular with normal skin in the center. Annular macules are observed in drug eruptions, secondary syphilis and lupus erythematosus. Iris lesions are a special type of annular lesion in which an erythematous annular macule or papule develops a second ring or a purplish papule or vesicle in the center (target or bull’s eye lesion).

Arrangement

A linear arrangement of lesions may indicate a contact reaction to an exogenous substance brushing across the skin. Zosterform refers to lesions arranged along the cutaneous distribution of a spinal nerve.

Size

It is important to measure some lesions, especially nevi and skin malignancies like squamous cell carcinoma. Squamous cell carcinoma of the skin greater than 2 cm in diameter is regarded to be high risk for recurrence and metastasis. Nevi larger than 6 mm in diameter are more likely to be malignant than smaller nevi.

Associated symptoms

Associated symptoms, like itching, pain, or burning sensation are helpful to make a diagnosis of certain skin diseases. Eczema tends to be itchy compared to fungal skin infections. Pain is usually associated with herpes simplex or herpes zoster.

Management

Eczema Treatment

Eczema treatment: Medium-strength corticosteroid cream to decrease inflammatory process. In addition, regular use of emollient to soften the lesion and prevent exacerbations. If the lesion is dry, ointment may be a better vehicle for the corticosteroid.

Topical Corticosteroids

Accurate diagnosis

An accurate diagnosis is essential in selecting a topical corticosteroid. Topical corticosteroids are effective for conditions that are characterized by hyperproliferation, inflammation, and immunologic involvement. They can also provide symptomatic relief for burning and pruritic lesions.

Vehicle

The vehicle, or base, is the substance in which the active ingredient is dispersed. The base determines the rate at which the active ingredient is absorbed through the skin. There are several types of vehicles:

Creams: The cream base is a mixture of several different organic chemicals (oils) and water, and usually contains a preservative. It can be used in nearly any area and therefore most often prescribed. It is cosmetically most acceptable. It has a drying effect with continuous use, therefore best for acute exudative inflammation.

Ointments: The ointment base contains a limited number of organic compounds consisting primarily of grease such as petroleum jelly, with little or no water. Ointment is desirable for drier skin and has a greater penetration of medicine than a cream and therefore has enhanced potency.

Lotions and gels: Lotions contain alcohol, which has drying effect on an oozing lesion. Lotions are most useful in the scalp area because they penetrate easily and leave little residue. Gels have a jelly-like consistency and are beneficial for exudative inflammation, such as poison ivy.

Potency

The anti-inflammatory properties of topical corticosteroids result in part from their ability to induce vasoconstriction to the small blood vessels in the upper dermis. The potency of corticosteroids are tabulated in seven groups, with group I the strongest and group VII the weakest.

Potency

Examples

Use to treat

Group I

Augmented betamethasone dipropionate 0.05%, Halobetasol propionate

0.05%

Psoriasis, lichen planus, severe hand eczema, and alopecia areata.

Group II

Desoximetasone, Fluocinonide 0.05%

Psoriasis, lichen planus, severe hand eczema, and alopecia areata.

Group III

Betamethasone dipropionate 0.05%, Triamcinolone acetonide 0.5% (ointment or cream)

Atopic dermatitis, nummular eczema, stasis dermatitis, and seborrheic dermatitis.

Group IV

Floucinolone acetonide 0.025% (ointment), Triamcinolone acetonide

0.1% (ointment)

Atopic dermatitis, nummular eczema, stasis dermatitis, and seborrheic dermatitis.

Group V

Floucinolone acetonide 0.025% (cream), Triamcinolone acetonide 0.1%

(lotion) or Triamcinolone acetonide 0.025% (ointment)

Atopic dermatitis, nummular eczema, stasis dermatitis, and seborrheic dermatitis.

Group VI

Alclometasone dipropionate 0.05%, Desonide 0.05%

Dermatitis in eyelids and diaper area, mild dermatitis on face, and mild intertrigo.

Group

VII

Hydrocortisone 1%, 2.5%

Dermatitis in eyelids and diaper area, mild dermatitis on face, and mild intertrigo.

Administration

Once or twice daily application is recommended for most preparations. More frequent administration does not provide better results.

Side effects

The most common side effect of topical corticosteroid is skin atrophy. It also can cause hypopigmentation. This is more apparent with darker skin tones. Topically applied high and ultra high potency corticosteroids can be absorbed well enough to cause systemic side effects. Hypothalamic-pituitary-adrenal suppression, glaucoma, septic necrosis of the femoral head, hyperglycemia, hypertension and other systemic side effects have been reported.

When to Treat with Systemic vs Local Antifungal Agents

Systemic Therapy

Tinea capitis

Oral therapy is required to adequately treat tinea capitis, as they are able to penetrate the infected hair shaft where topical therapies cannot.

Griseofulvin is the first-line oral antifungal treatment approved for use. Suggested dosing is 20-25 mg/kg/day using the microsize formulation, for 6-12 weeks. Where the ultramicrosize formulation is used, a dose of 10-15 mg/kg/day is suggested, as it is more rapidly absorbed than the microsize form.

Terbinafine hydrochloide was also approved by FDA in 2007 for tinea capitis for children ages 4 years and older. The approved pediatric dose of terbinafine granule is 125 mg, 187.5 mg, or 250 mg for children weighing less than 25 kg, 25 to 35 kg, and more than 35 kg, respectively, once daily for 6 weeks.

In multiple studies, terbinafine was consistently more effective than griseofulvin against tinea capitis caused by Trichophyton tonsurans. However, in children with microsporum infection, new evidence suggests that the effect of griseofulvin is better than that of terbinafine.

Tinea unguium

Though griseofulvin is approved for tinea infection of the nails, its affinity for keratin is low and long-term therapy is required. The oral therapy regimens for tinea unguium (onychomycosis)are as follows:

terbinafine 250 mg/day for 12 weeks (toenails) or 6 weeks (fingernails only) itraconazole 200 mg twice daily as pulse therapy one pulse: 1 week of itraconazole followed by 3 weeks without itraconazole two pulses: fingernails three pulses: toenails Local Therapy

Tinea pedis, tinea manuum, tinea corporis, and tinea cruris can be treated with topical antifungal medications.

A wide variety of topical agents are available, in cream, gel, lotion, and shampoo formulations. A majority of the agents are of the ‘azole’ antifungal family (clotrimazole, miconazole, econazole, coiconazole, ticonazole, etc.). Terbinafine and naftifine represent the ‘allylamine’ family of agents. Both families of drugs are known for their high efficacy against the dermatophytes.

Cure rates of tinea corporis/tinea cruris/tinea pedis are high, with infections resolving with two to four weeks of topical therapy.

Skin Biopsy

Type of biopsy

Procedure

Tool & specimen size

Incisional /

punch biopsy

Incisional biopsy means taking out a part of the skin lesion

Punch biopsy is a specific incisional biopsy using a cylindrical dermal biopsy tool.

Disposable punches are very convenient and available from two to eight millimeters in size.

A full thickness of skin can easily be obtained with a punch biopsy.

If a lesion is less than three millimeters in size, it does not need stitches after biopsy.

Excisional biopsy

Excisional biopsy involves removing the whole lesion with a two to three millimeter margin, depending on the nature of the lesion.

Larger-sized punches may be useful for excisional punch biopsies.

Diagnostic method of choice if there is a strong suspicion of malignant melanoma.

Shave biopsy

Shave biopsy is feasible when the lesion is elevated above the surface.

Some experts occasionally elevate the lesion with lidocaine and shave in certain circumstances in order to avoid stitches.

Skin Lesion Therapy

Therapy

Conditions treated

More details

Surgical excision

Most widely used treatment for cutaneous squamous-cell carcinomas (SCCs), particularly high risk lesions.

Well defined, small (< 2 centimeters) SCC lacking any high-risk features requires a four millimeter margin of normal tissue around the visible tumor to result in 95% histologic cure rate.

Patients with any nonmelanoma skin cancer greater than two centimeters,

The surgeon can immediately review the pathology to confirm complete excision during a staged excision. Since this allows removal of the least

Mohs

microscopic surgery

lesions with indistinct margins, recurrent lesions, and those close to important structures, including the eyes, nose, and mouth, should be considered for referral for complete excision via Mohs micrographic surgery, with possible plastic repair.

necessary amount of tissue, this procedure is indicated in cosmetically sensitive areas. This ability to immediately confirm pathology is also useful in lesions with indistinct margins where more tissue than clinically apparent may require removal. If a difficult repair is anticipated or a poor cosmetic result is expected, referral is appropriate. To learn more about Mohs surgery, read an article from the American Academy of Family Physicians.

Topical 5fluorouracil

(5-FU)

Approved by the United States Food and Drug Administration (FDA) for the treatment of actinic keratoses.

Although topical 5 -FU is not approved for the treatment of Bowen’s disease (squamous-cell carcinoma in-situ) and superficial SCCs, it is widely used in these diseases when other treatment modalities are impractical and for patients who refuse surgical treatment.

Cryotherapy

Useful for small, well defined, low risk invasive SCCs and Bowen’s disease.

Destroys malignant cells by freezing and thawing. Cryotherapy does not permit histologic confirmation of the adequacy of treatment margins; thus, a substantial amount of training and experience is required to achieve consistently high cure rates.

Radiation therapy

An option for the initial management of small, well-defined, primary SCCs, especially older patients and those who are not surgical candidates.

However radiation therapy is contraindicated on tumors located on trunk and extremities. These areas are subjected to greater trauma and tension than skin on the head and neck, and they are more prone to break down and ulcerate as a result of the atrophy and poor vascularity of irradiated tissue.

Management of Symptomatic Benign Prostatic Hyperplasia (BPH)

Behavior modifications to decrease lower urinary tract symptoms:

avoiding fluids prior to bedtime or before going out

reducing consumption of mild diuretics such as caffeine and alcohol limiting the use of salt and spices maintaining voiding schedules

Alpha-adrenergic antagonists decrease urinary symptoms in most males with mild to moderate BPH. Alpha-adrenergic antagonists include tamsulosin, alfuzosin, terazosin and doxazosin. The American Urology Association (AUA) Guidelines Committee believes that all four medications are equally effective.

5-alpha-reductase inhibitors are more effective in males with larger prostates. Their effect on preventing acute urinary retention and reduction in need of surgery require long term treatment for more than a year. There are two 5-alpha-reductase inhibitors approved in the United States: finasteride and dutasteride.

In males with severe symptoms, those with a large prostate (>40 g), and in those who do not get an adequate response to maximal dose monotherapy with an alpha-adrenergic antagonist, combination treatment with an alpha-adrenergic antagonist and a 5-alpha-reductase inhibitor may be desirable.

In general, if bladder outlet obstruction is creating a risk for upper urinary tract injury such as hydronephrosis, renal insufficiency, or lower urinary tract injury such as urinary retention, recurrent urinary tract infection, or bladder decompensation; surgical intervention is needed. Surgery also should be considered if combination treatment fails to improve symptoms of BPH.

Benign Prostatic Hyperplasia (BPH) Treatment

BPH treatment focuses on relieving symptoms.

Instruct patients to:

Give yourself time to urinate completely.

Do not drink alcohol, drinks with caffeine in them (coffee, tea, colas), or other fluids in the evening. Do not take decongestants like Sudafed.

Do not take antihistamines like Benadryl.

For moderate to severe symptoms (AUA score of 8 or more), prescribe alpha blockers to cause the muscles of the urethra to relax. Side effects of alpha blockers: feeling tired or sleepy.

Studies

Clinical manifestation

Lower urinary tract symptoms (LUTS)

hesitancy urgency weak urinary stream

These symptoms typically appear slowly and progressively over a period of years.

Other conditions with similar symptoms

urinary tract and prostatic infections medication side effects, overactive bladder prostate cancer

Complications of untreated BPH

urinary tract infections acute urinary retention obstructive nephropathy

When evaluating for BPH, perform:

Digital rectal exam should be done to assess prostate size and consistency and to detect nodules, indurations, and asymmetry — all of which raise suspicion for malignancy. Rectal sphincter tone should also be determined.

Urinalysis should be done to detect urinary tract infection and blood, which could indicate bladder cancer or stones. Serum prostate specific antigen (PSA) level determination is recommended for males with a life expectancy of 10 years or longer and for those whose PSA level may influence BPH treatment. This includes most patients who are considering treatment with a 5-alpha reductase inhibitor. This practice should be distinguished from recommendations about utilizing the PSA as a screening test. In this case, the patient actually has symptoms that could represent prostate cancer; screening is only for asymptomatic individuals.

Clinical Reasoning

Differential of Oval-Shaped, Erythematous 18 x 16 mm Patch

Most Likely Diagnoses

Eczema

Eczema can appear erythematous and is often pruritic.

Typically occurs behind the ears and on flexural areas.

Squamous cell

carcinomas

Squamous cell carcinomas are scaly and erythematous but, unlike actinic keratoses, tend have a raised base.

Lesions may take the form of a patch, plaque, or nodule, sometimes with scaling and/or an ulcerated center.

Borders are often irregular and bleed easily.

Unlike basal cell carcinomas, the heaped-up edges of a squamous cell carcinoma are fleshy rather than clear in appearance.

Squamous cell carcinoma comprises 20 percent of all cases of skin cancer.

History of significant sun exposure is a risk factor for squamous cell carcinoma and it typically occurs on areas of the skin that have been exposed to sunlight for many years, such as the extremities or face.

Actinic keratoses

Actinic keratoses are scaly keratotic patches that are often more easily felt than seen.

A history of significant sun exposure is a risk factor for actinic keratosis.

Basal cell carcinomas

Basal cell carcinomas may be plaque-like or nodular with a waxy, translucent appearance, often with ulceration and/or telangiectasia.

Usually there is no associated itching or change in skin color.

Basal cell carcinoma is common on the face and on other exposed skin surfaces but may occur anywhere.

Comprising 60 percent of primary skin cancers, basal cell carcinomas are typically slow-growing lesions that invade local tissues but rarely metastasize.

A long history of sun exposure is a risk factor for basal cell carcinoma.

In the United States, the median age at diagnosis of melanoma is 53, with about one in four new cases

Melanoma

occurring in those younger than 40 years.

Lesions that are growing, spreading or pigmented, or those that occur on exposed areas of skin are of particular concern for melanoma.

Although it comprises only 1 percent of all skin cancers, malignant melanoma accounts for over 60 percent of skin cancer deaths.

The lesions of superficial spreading melanoma are dark brown or black.

Slowly spreading irregular outline in the initial phase. Some areas may be a lighter shade.

Since not all malignant melanomas are visibly pigmented, physicians should be suspicious of any lesion that is growing or that bleeds with minor trauma.

More than half of melanoma in females occurs on the legs.

Sun exposure is a risk factor for melanoma; studies have shown that the prevalence of melanoma increases with proximity to the equator.

Persons with skin types that burns easily and tans with difficulty, and with red or blond hair, and freckles are at higher risk.

Although cumulative sun exposure is linked to nonmelanoma skin cancer, intermittent intense sun exposure seems to be more related to melanoma risk.

Fungal infection

Can have acute, erythematous appearance.

Less Likely Diagnoses

Psoriasis

Psoriasis is usually bilateral and involves extensor surfaces of elbows and knees.

Although psoriasis can present with involvement in patches, it usually plaque-like, with scaly, elevated lesions.

Lichen planus

Lichen planus typically presents as 2-10 mm flat-topped papules with an irregular, angulated border (polygonal papules) that are commonly located on the flexor surface of wrists and and on the legs immediately above the ankles.

Most of the times, the lesions are multiple.

Lichen planus is common in middle age.

Seborrheic keratoses

Elevated hyperpigmented lesions with a well-circumscribed border, stuck-on appearance, and variable tanbrown-black color and are most commonly located on the face and trunk.

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