NR-511 Wk4 Abdominal SOAP Assignment

NR-511 Wk4 Abdominal SOAP

NR-511 Wk4 Abdominal SOAP

NR 511 Differential Diagnosis and Primary Care Practicum

Soap Note

Patrick 42 years old

S:  Subjective

Chief Complaint (CC): Abdominal

History of present illness (HPI): O: Sudden abdominal pain. L.  One side of back: D: ongoing, since 5.am today.  C: Worsening, pain, throbbing pain to stomach. A: shooting pain down into groin.. R: none  T: Not provided. S Restless, frequent bathroom breaks, pain of 8/10

 

Current Medications:  None,

Allergies: NKDA Seasonal allergies: Hay fever.

PMHx: Psoriasis Immunizations: up to date

Hospitalization broken leg at age 8, requiring traction

surgical hx:, Appendectomy at 10

Family Hx Parents are deceased. Mother(died at age 51 from a brain tumor.

Father died at age 53 from leukemia. Has one brother in good health.

Soc Hx: Works as a plumber. Sleeps 5-6 hours a night, smokes 1 ppd, No ETOH or illicit drug use

 

CONSTITUTIONAL:  Denies recent weight loss, doesn’t think she has fever, chills. Reports weakness or fatigue.

HEENT: Patrick denies any visual loss, blurred vision, and double vision. No drainage or exudate in ears. No hearing loss, Nose: no sneezing, congestion and runny nose, no sore throat. SKIN:  Skin color is pale pink, no cyanosis or pallor.  CARDIOVASCULAR:  denies chest pain or palpitations. No chest pain, chest pressure or chest discomfort. No palpitations or edema. RESPIRATORY:  No shortness of breath, denies cough, increased pain to face, during breathing. GASTROINTESTINAL:  No anorexia or vomiting. Patrick reports nausea and shooting abdominal pain that radiates to groin.  Denies blood in stool. GENITOURINARY:  denies urine frequency, or bladder problem. NEUROLOGICAL:  Reports headache, denies dizziness, and syncope. No paralysis, ataxia, numbness or tingling in the extremities. MUSCULOSKELETAL: reports throbbing back pain, no joint pain or stiffness. HEMATOLOGIC:  No anemia, bleeding or bruising. LYMPHATICS:  Denies Swelling, tenderness, drainage. No history of splenectomy. PSYCHIATRIC:  denies depression, no anxiety. ENDOCRINOLOGIC: no polyuria, polydipsia and night sweating, no cold or heat intolerance.

 

O.

Vital Signs T- 98.9, BP 160/96, P 100, R 22, oxygen saturation: 98%.

 

Physical Exam:

Patrick is a 42-year-old, well appearing, well nourished; who presents with complain of an abdominal pain that started this around 5a.m today. Pain is increasingly worst and uncomfortable, radiating to one side of back and down to groin. Oriented x 3 dull mood; and flat affect, but cooperative. Reports nausea and fever.

HEENT: …

Assessment :

…

Treatment Plan :

…

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References

De, S., & Sivalingam, S. (2014). What to Do About Asymptomatic Calculi. Pocket Guide to Kidney Stone Prevention, 131–136. doi:10.1007/978-3-319-11098-1_15

Marsden, J. (2014). Mosby’s Manual of Diagnostic and Laboratory Tests Pagana Kathleen and Pagana Timothy Mosby’s Manual of Diagnostic and Laboratory Tests. Elsevier. Emergency Nurse, 22(4), 13–13. doi:10.7748/en.22.4.13.s14

Rao, N. P., Preminger, G. M., & Kavanagh, J. P. (Eds.). (2011). Urinary Tract Stone Disease. doi:10.1007/978-1-84800-362-0

NR 511 Coursework Week 1 to 8
NR 511 Week 1 Assignment, Clinical Readiness Exam
NR 511 Week 1 Study Guide (View Details)

NR 511 Week 2 Reading, Chapter 11 Review – Abdominal Problems

NR 511 Week 3 Case Study Discussion: Part One
NR 511 Week 3 Case Study Discussion: Part Two

NR 511 Week 4 Midterm Exam (Study Guide Week 1, 2 and 3)
NR 511 Week 4 Midterm Exam (5 Versions / 250 Questions & Answers)

NR 511 Week 5 Assignment, SNAPPS PowerPoint Background (Guide)
NR 511 Week 5 Assignment, SNAPPS Presentation Template

NR 511 Week 6 Case Study Discussion: Part One
NR 511 Week 6 Case Study Discussion: Part One

NR 511 Week 7 Assignment, Clinical Practice Guideline Peer Review Discussion

NR 511 Week 8 Assignment, Reflection
NR 511 Week 8 Final Exam Study Guide (Questions and Answers)
NR 511 Week 8 Final Exam (100 Questions & Answers)
NR 511 Power Point Transcript, Polycystic Ovary Syndrome
NR 511 Completed Learning Agreement Week 1 and Week 8

NR 511 eELOGS Frequently Asked Questions

NR 511 Week 7 Assignment

Clinical guidelines provide recommendations on the diagnosis and management of certain conditions. Recommendations are based on evidence from a rigorous systematic review and synthesis of the published medical literature. Interpreting and learning to apply guidelines into practice is necessary to develop and enhance diagnostic reasoning skills.

Due Date
Students will RANDOMLY assigned a topic by your instructor in Week 1. Students will post a brief PowerPoint summary presentation by Week 7. This will allow others to view their peer’s presentations in order to provide peer evaluations before Sunday. Presentations submitted after Week 7 will receive an automatic 0.

Requirements

1. Students will randomly assigned a disease topic from the instructor in Week 1.
2. Each student will locate and examine a current CPG for the assigned topic.
3. A copy (or reference) of the intended CPG should submitted to the instructor by Week 3 for approval.
4. In Week 7, students will summarize the CPG and give a brief, Oral Presentation according to the directions and rubric listed below.
5. In addition to the presentation, a Written Transcript (for instructor) must submitted to Week 7 assignment box.
6. Students will share a copy of the CPG along with a link to their presentation.
7. Presentations and transcripts are due before … of Week 7, Presentations and/or papers submitted after the deadline will receive an automatic 0.