NSG 6020 WK 7 iHuman Soap Note – Cancer Risk Examination

NSG 6020 WK 7 iHuman Soap Note – Cancer Risk Examination

NSG 6020 WK 7 iHuman Soap Note – Cancer Risk Examination

SOAP NOTE

Name: Mrs. C	Date: May 18, 2018	Time: 4PM
	Age: 41 years old	Sex: Female
SUBJECTIVE
CC: “I’m just here for a wellness check-up. I just want to know my risks of having breast cancer since my mother and my cousin was recently diagnosed with one.”
HPI: Seen and examined Mrs. C, a 41-year old healthy Hispanic – American Female presented in the clinic for a well-woman examination. She denies having any active medical condition but voices out concerns regarding breast cancer risk as her mother and maternal cousin was just recently diagnosed with it. Patient reports having a history of fibrocystic heart disease. Denies any pain or discomfort. Last mammogram check was 18 months ago and was normal. Patient also states that she does regular self-breast examination and denies finding any lumps or having discharges. NSG 6020 WK 7 iHuman Soap Note – Cancer Risk Examination.
Medications: Vitamin E daily for Fibrocystic changes Aspirin or Acetaminophen as needed for headaches
PMH Allergies: No known Allergies Medication Intolerances: None Chronic Illnesses/Major traumas: Fibrocystic changes Hospitalizations/Surgeries OB/GYN: G2P2 Tubal ligation: (35 years of age on second pregnancy)
Family History Mother – Breast Cancer (Dx 2 months ago) Father – Hypertension and Hyperlipidemia Patient has 2 sons both healthy Patient has 2 brothers both healthy Maternal cousin – Breast Cancer (recently diagnosed) Indicates Patient Living Male             Living Female

Weight 155 lbs BMI 27.5	Temp 98.4	BP 134/74
Height 5’3”	Pulse 76 years old	Resp 16
General Appearance Seen and examined Mrs. C, 41-year old healthy Hispanic-American female for a well-woman examination. Appears to be pleasant, mobile, and active. NSG 6020 WK 7 iHuman Soap Note – Cancer Risk Examination. Alert and oriented x 4, answers all questions appropriately and very cooperative.
Skin Intact, warm to touch and dry with no bruising, lesions, rashes or discoloration noted. No cyanosis or clubbing noted. No visible scars observed.
HEENT  ·        Normocephalic ·        Conjunctiva pink,  sclerae white, no jaundice, free from drainage, PERRLA. ·        Ears non-tender, no swelling and free from drainage ·        Nose: nasal mucosa moist without drainage, septum midline, free from swelling and lesions ·        Throat: free from lesions and not enlarged ·        Neck: Trachea is midline, non-palpable thyroid and lymph nodes, neck supple with no masses or tenderness.
Cardiovascular S1, S2 with regular rate and rhythm. No extra sounds, clicks, rubs or murmurs. Capillary refill 2 seconds. Pulses 3+ throughout. No edema.
Respiratory Symmetrical chest expansion. Respirations even and unlabored, breath sounds clear upon ausculatation bilaterally. No wheeing, rhonchi, or stridor noted. No increased tactile fremitus.
Gastrointestinal  Abdomen flat, soft, non-distended, Bowel sounds present on all quadrants. Abdomen tympanic with percussion, Non-tender when palpated and no hepatosplenomegaly. NSG 6020 WK 7 iHuman Soap Note – Cancer Risk Examination.
Breast -Normal, symmetrical breast contour – No visible or nipple abnormalities -No spontaneous or expressed nipple discharge or blood -Irregular “lumpy bumpy” consistency throughout both breasts; no suspicious, discrete palpable lesions. -Slight, diffuse tenderness to exam reported.
Genitourinary  -Normal external genitalia – Parous introitus -Normal vaginal mucosa -Cervical eversion (ectropion) without friability; samples collected for pap smear. -Normal abnormal discharge -Uterus firm, slightly irregular in contour per bimanual exam

NSG 6020 WK 7 iHuman Soap Note – Cancer Risk Examination

References:

iHuman (2018) Carolyn Cross V2VE  retrieved from https://app.i-human.com/player?env=production&play_mode=PARTIAL_REVIEW&referer=https%3A%2

Menefee, L., & Monti, D., (2005) The American Journal of the American Osteopathic Association: Nonpharmacologic and complementary approaches to cancer pain management retrieved from http://jaoa.org/article.aspx?articleid=2093165.

NSG 6020 Week 8 Discussion

The discussion assignment provides a forum for discussing relevant topics for this week based on the course competencies covered.

For this assignment, go to the Discussion Area and post a response to the given question in the Discussion Area by the due date assigned.

To support your work, use your course and text readings and also use the South University Online Library. As in all assignments, cite your sources in your work and provide references for the citations in APA format.

Start reviewing and responding to the postings of your classmates as early in the week as possible. Respond to at least two of your classmates’ initial postings. Participate in the discussion by asking a question, providing a statement of clarification, providing a point of view with a rationale, challenging an aspect of the discussion, or indicating a relationship between two or more lines of reasoning in the discussion. Cite sources in your responses to other classmates. Complete your participation for this assignment by the end of the week.

Assignment

Complete only the History, Physical Exam, and Assessment sections of the iHuman case: Christine Smith V3

Click here for information on how to access and navigate iHuman.

Discussion Question 1

Based on your performance and the expert feedback in your HISTORY collection, describe two missed questions and your understanding of why they were important to collect for this case history. Use specific references from your text to explain.

Discussion Question 2

Based on your performance and the expert feedback in your PHYSICAL EXAM collection, describe two errors in your exam performance or documentation. Use specific references from your text to explain the importance of these findings in correct assessment of this client.

Discussion Question 3

Based on your performance on the PHYSICAL EXAM collection, describe one key finding that you included in your list and describe a specific physical exam that you can perform at the point-of-care to further evaluate the finding. Use specific references from your text.

Discussion Question 4

Based on your performance and the expert feedback in your ASSESSMENT identification of problem categories, choose one missed/incorrect category and use specific references from your text to explain the importance of this category in arriving at correct differential diagnoses for this client.

Discussion Question 5

Based on your performance and the expert feedback in your ASSESSMENT of differential diagnoses, describe one incorrect/missed differential diagnosis and use specific references from your text to support the inclusion of the diagnosis for this client. NSG 6020 WK 7 iHuman Soap Note – Cancer Risk Examination.

Week 9 Discussion

The discussion assignment provides a forum for discussing relevant topics for this week based on the course competencies covered.

For this assignment, go to the Discussion Area and post a response to the given question in the Discussion Area by the due date assigned.

To support your work, use your course and text readings and also use the South University Online Library. As in all assignments, cite your sources in your work and provide references for the citations in APA format.

Start reviewing and responding to the postings of your classmates as early in the week as possible. Respond to at least two of your classmates’ initial postings. Participate in the discussion by asking a question, providing a statement of clarification, providing a point of view with a rationale, challenging an aspect of the discussion, or indicating a relationship between two or more lines of reasoning in the discussion. Cite sources in your responses to other classmates. Complete your participation for this assignment by the end of the week.

Assignment

Complete only the History, Physical Exam, and Assessment sections of the iHuman case: Gloria Jenkins V3 PC

Click here for information on how to access and navigate iHuman. NSG 6020 Course Discussion Assignment Papers.

Discussion Question 1

Based on your performance and the expert feedback in your HISTORY collection, describe two missed questions and your understanding of why they were important to collect for this case history. Use specific references from your text to explain.

Discussion Question 2

Based on your performance and the expert feedback in your PHYSICAL EXAM collection, describe two errors in your exam performance or documentation. Use specific references from your text to explain the importance of these findings in correct assessment of this client.

Discussion Question 3

Based on your performance on the PHYSICAL EXAM collection, describe one key finding that you included in your list and describe a specific physical exam that you can perform at the point-of-care to further evaluate the finding. Use specific references from your text.

Discussion Question 4

Based on your performance and the expert feedback in your ASSESSMENT identification of problem categories, choose one missed/incorrect category and use specific references from your text to explain the importance of this category in arriving at correct differential diagnoses for this client.

Discussion Question 5

Based on your performance and the expert feedback in your ASSESSMENT of differential diagnoses, describe one incorrect/missed differential diagnosis and use specific references from your text to support the inclusion of the diagnosis for this client.

Week 10 Discussion

The discussion assignment provides a forum for discussing relevant topics for this week based on the course competencies covered.

For this assignment, go to the Discussion Area and post a response to the given question in the Discussion Area by the due date assigned.

To support your work, use your course and text readings and also use the South University Online Library. As in all assignments, cite your sources in your work and provide references for the citations in APA format.

Start reviewing and responding to the postings of your classmates as early in the week as possible. Respond to at least two of your classmates’ initial postings. Participate in the discussion by asking a question, providing a statement of clarification, providing a point of view with a rationale, challenging an aspect of the discussion, or indicating a relationship between two or more lines of reasoning in the discussion. Cite sources in your responses to other classmates. Complete your participation for this assignment by the end of the week.

Assignment

Complete only the History, Physical Exam, and Assessment sections of the iHuman case: Bebe Babbitt V4 PC

Click here for information on how to access and navigate iHuman.

ORDER NOW FOR CUSTOM-WRITTEN SOLUTIONS

Discussion Question 1

Based on your performance and the expert feedback in your HISTORY collection, describe two missed questions and your understanding of why they were important to collect for this case history. Use specific references from your text to explain.

Discussion Question 2

Based on your performance and the expert feedback in your PHYSICAL EXAM collection, describe two errors in your exam performance or documentation. Use specific references from your text to explain the importance of these findings in correct assessment of this client.

Discussion Question 3

Based on your performance on the PHYSICAL EXAM collection, describe one key finding that you included in your list and describe a specific physical exam that you can perform at the point-of-care to further evaluate the finding. Use specific references from your text.

Discussion Question 4

Based on your performance and the expert feedback in your ASSESSMENT identification of problem categories, choose one missed/incorrect category and use specific references from your text to explain the importance of this category in arriving at correct differential diagnoses for this client.

Discussion Question 5

Based on your performance and the expert feedback in your ASSESSMENT of differential diagnoses, describe one incorrect/missed differential diagnosis and use specific references from your text to support the inclusion of the diagnosis for this client. NSG 6020 WK 7 iHuman Soap Note – Cancer Risk Examination.

Week 5 SOAP Note Assignment

SOAP Note

Each week you are required to enter your patient encounters into CORE. Your faculty will be checking to ensure you are seeing the right number and mix of patients for a good learning experience. Beginning in Week 5, you will need to include one complete SOAP note each week through Week 9 for a total of 5 complete SOAP notes for this course using this SOAP note template. The SOAP note should be related to the content covered in this week, and the completed SOAP note should be submitted to the Submissions Area. When submitting your note, be sure to include the reference number from CORE where you entered this specific patient’s case entry.

Submission Details:

By the due date assigned, enter your patient encounters into CORE and complete at least one SOAP note in the template provided.

Name your SOAP note document SU_NSG 6020_W5_A2_LastName_FirstInitial.doc.

Include the reference number from CORE in your document.

Submit your document to the Submissions Area by the due date assigned.

Week 6 SOAP Note Assignment

SOAP Note

Each week you are required to enter your patient encounters into CORE. Your faculty will be checking to ensure you are seeing the right number and mix of patients for a good learning experience. Beginning in Week 5, you will need to include one complete SOAP note each week through Week 9 for a total of 5 complete SOAP notes for this course using this SOAP note template. The SOAP note should be related to the content covered in this week, and the completed SOAP note should be submitted to the Submission Area. When submitting your note, be sure to include the reference number from CORE where you entered this specific patient’s case entry.

Submission Details:

By the due date assigned, enter your patient encounters into CORE and complete at least one SOAP note in the template provided.

Name your SOAP note document SU_NSG 6020_W6_A4_LastName_FirstInitial.doc.

Include the reference number from CORE in your document.

Submit your document to the Submissions Area by the due date assigned. NSG 6020 Course Discussion Assignment Papers.

Week 6 Physical Exam Video and Write Up Assignment

Complete Health History and Physical Assessment Write-Up Presentation

This assignment consists of complete head to toe physical while being videoed. You will also need to complete a written assignment of your findings. Review the Expanded rubric to note how you will be graded on this assignment.

Week 7 SOAP Note Assignment

Each week you are required to enter your patient encounters into CORE. Your faculty will be checking to ensure you are seeing the right number and mix of patients for a good learning experience. Beginning in Week 5, you will need to include one complete SOAP note each week through Week 9 for a total of 5 complete SOAP notes for this course using this SOAP note template. The SOAP note should be related to the content covered in this week, and the completed SOAP note should be submitted to the Submissions Area. When submitting your note, be sure to include the reference number from CORE where you entered this specific patient’s case entry.

Submission Details:

By the due date assigned, enter your patient encounters into CORE and complete at least one SOAP note in the template provided.

Name your SOAP note document SU_NSG 6020_W7_A3_LastName_FirstInitial.doc.

Include the reference number from CORE in your document.

Submit your document to the Submissions Area by the due date assigned. NSG 6020 Course Discussion Assignment Papers.

ORDER NOW FOR CUSTOM-WRITTEN SOLUTIONS

Week 8 SOAP Note Assignment

SOAP Note

Each week you are required to enter your patient encounters into CORE. Your faculty will be checking to ensure you are seeing the right number and mix of patients for a good learning experience. Beginning in Week 5, you will need to include one complete SOAP note each week through Week 9 for a total of 5 complete SOAP notes for this course using this SOAP note template. The SOAP note should be related to the content covered in this week, and the completed SOAP note should be submitted to the Submissions Area. When submitting your note, be sure to include the reference number from CORE where you entered this specific patient’s case entry.

Submission Details:

By the due date assigned, enter your patient encounters into CORE and complete at least one SOAP note in the template provided.

Name your SOAP note document SU_NSG 6020_W8_A3_LastName_FirstInitial.doc.

Include the reference number from CORE in your document.

Submit your document to the Submissions Area by the due date assigned.

Week 9 SOAP Note Assignment

SOAP NOTE

Each week you are required to enter your patient encounters into CORE. Your faculty will be checking to ensure you are seeing the right number and mix of patients for a good learning experience. Beginning in Week 5, you will need to include one complete SOAP note each week through Week 9 for a total of 5 complete SOAP notes for this course using this SOAP note template. The SOAP note should be related to the content covered in this week, and the completed SOAP note should be submitted to the Submissions Area. When submitting your note, be sure to include the reference number from CORE where you entered this specific patient’s case entry.

Submission Details:

By the due date assigned enter your patient encounters into CORE and complete at least one SOAP note in the template provided. NSG 6020 Course Discussion Assignment Papers.

Name your SOAP note document SU_NSG 6020_W9_A3_LastName_FirstInitial.doc.

Include the reference number from CORE in your document.

Submit your document to the Submissions Area by the due date assigned.