Environmental hazards: Patient denies any environmental hazards. Thesis papers will only be handled by Masters Degree holders while Dissertations will strictly be handled by PhD holders. The other symptoms include urethral discharge, dysuria, hematuria (Cash, 2014), Kidney Stone: Add Ct scan to determine the stone size, if the test of urine positive for renal calculi. Education level, occupational history, current living situation/partner/marital status, substance use/abuse, ETOH, tobacco, marijuana. If changes are needed, request a revision. No hepatosplenomegaly. Prostrate is smooth, non-tender and free from nodules, is of normal size, sphincter tone is firm. Describe the evaluation tool and explain why this tool is essential in the care of the adolescent patient population. " I came to iHuman because I was homeless and I was new to the city. Anyone diagnosed with: lung disease, heart disease, htn, cancer, TB, DM, or kidney disease. Quality isnt just an option, it is the only option. Respirations regular and easy; lungs clear to auscultation bilaterally. ORDER A CUSTOM-WRITTEN, PLAGIARISM-FREE PAPER HERE Tetanus booster vaccine in 2010. Scrotal ultrasound reveals the following: Normal testicular size bilaterally (Fischbach & Dunning, 2014). External genitalia reveals coarse pubic hair in normal distribution; skin color is consistent with general pigmentation. Jack Baldwin VE iHuman Episodic SOAP Note and Differential Diagnoses Examples. IHuman - SCOTT BALDWIN (SEIZURE) - NUR 4045 (NUR4045) - Stuvia US. Dressed in clean slacks, shirt and coat. Consider the following: Tariffs are paid by the citizens of the country, Mean corpuscular hemoglobin concentration (MCHC). Retrieved on November 21, 2016, from https://www.cms.gov/medicare-coverage-database/staticpages/icd-10-code-lookup.aspx Jack Baldwin VE iHuman Episodic SOAP Note and Differential Diagnoses Examples. The pain is severe, constant, and feels like something is tearing inside. He is nauseated, has vomited once but denies dysuria, hematuria, back/leg pain, numbness, or weakness. Ovaries are non-palpable. Testicular torsion: sudden onset of pain which is exquisite tenderness; and a high-riding, horizontally displaced testis (Goolsby & Grubbs, 2015). IHuman - SCOTT BALDWIN (SEIZURE) - $14.49 Add to cart. No edema. Musculoskeletal: Full ROM seen in all 4 extremities as patient moved about the exam room. Jack Baldwin VE iHuman Episodic SOAP Note and Differential Diagnoses Examples. He states the patin is often as 8 or 10 out of 10 severity. Avoid contact with infants, children, pregnant women, and adults who have never had chicken pox, until blisters are completely dry. EOMs intact. Please note that your SOAP note has several areas that have required information. Recommend smoking cessation patient not ready (Buttaro, Trybulski & Bailey, 2013). No hepatosplenomegaly. The scrotum is swollen on left side. RRR, S1 and S2 present. Alert and oriented; answers questions appropriately. Postoperative evaluation for hernia recurrences as needed (Cash, 2014). Full ROM; no cervical lymphadenopathy; no occipital nodes. The testicles are normal in size and nontender to palpation. Reason given by the patient for seeking medical care in quotes. Speech is soft, though clear and of normal rate and cadence; cant answer questions appropriately. HPI: Mr. Baldwin is a 50-year old male who experienced the sudden onset of severe pain in his left groin radiating to his testicles after moving a refrigerator 6 hours ago. Respirations regular and easy; lungs clear to auscultation bilaterally. Right side normal. Jack L. Baldwin <p>Jack L. Baldwin, 65, of El Cajon, California passed away on April 22, 2022 at Windsor Garden Care Center after an extended illness.</p> <p>Jack was the son of Don and Ethel Mae Baldwin of Elroy. Describe the course of the patients illness, including when it began, character of symptoms, location where the symptoms began, aggravating or alleviating factors; pertinent positives and negatives, other related diseases, past illnesses, surgeries or past diagnostic testing related to present illness. The scrotum is swollen on left side. Thepain should ease within two to three days. Your account will be created automatically. Students can be assigned cases individually, in a lecture, a flipped classroom or in a team-based learning environment. No vulvar lesions noted. Slightly somber affect at first, then brighter later. Patient states he began to feel a tingling and burning sensation to the area approximately 48 hours age, and then blisters appeared 24 hours ago. Advise that a person sho has never had chicken pox may contract chicken pos by exposure to the shingles rash. 34K views 4 years ago i-Human Patients 2.1K views 7 years ago Poets & Quants 431K views 3 years ago Pulmonary. Abdomen obese; BS active in all 4 quadrants. Complains of rash to middle of right side of back. Pulses 3+ throughout. Jack Baldwin VE iHuman Episodic SOAP Note and Differential Diagnoses Examples, Chief Complaint (CC): severe left groin pain for 6 hours. ICD-10 Code Lookup. No conjunctival or scleral injection. Non-medication treatments:Maintain adequate hydratin b continuing to drink 68 glasses of water a day. BMI: 24.4 Temp: 99 (Oral)BP: 170/94. Born November 24, 1956, Jack grew up in Elroy and graduated from Royall High School in 1974.</p> <p>His childhood was marked by a . Avoid contact with infants, children, pregnant women, and adults who have never had chicken pox, until blisters are completely dry. Testicular torsion: sudden onset of pain which is exquisite tenderness; and a high-riding, horizontally displaced testis (Goolsby & Grubbs, 2015). Nutrition: recommending better choices when eats out (Buttaro, Trybulski & Bailey, 2013). Uterus is antevert and positioned behind a slightly distended bladder; no fullness, masses, or tenderness. Avoid contact with infants, children, pregnant women, and adults who have never had chicken pox, until blisters are completely dry. A small speculum was inserted; vaginal walls are pink and well rugated; no lesions noted. Tactile fremitus equal bilaterally. Does not cross midline. Nose: Nasal mucosa pink; normal turbinates. Tenderness is appreciated in the left inguinal canal; the scrotum is swollen on the left side; the testicles are normal in size and nontender to palpation. Nutrition: recommending better choices when eats out (Buttaro, Trybulski & Bailey, 2013). Surgery is an effective treatment, laparoscopy or through an open procedure or mesh repair depending the size of the hernia, and the onset of strangulation. Posture erect. The left groin region is visibly swollen and indurated to palpation. 4 pages. Ours isnt a collection of individuals who are good at searching for information on the Internet and then conveniently re-writing the information obtained to barely beat Plagiarism Software. He played college football for Centenary in Louisiana and professional football for the New York Yankees, San Francisco 49ers, Buffalo Bills, and Edmonton Eskimos . : Mosby/Elsevier. Denies bruising or other abnormalities to skin, hair, or nails. Jack Baldwin VE iHuman Episodic SOAP Note - School Academy . Use this weeks iHuman case titled Jack Baldwin VE and create a SOAP note with a treatment plan (located at the bottom of the SOAP note. Maintains eye contact. Abdomen obese; BS active in all 4 quadrants. Hernia inguinal K40 (ICD-10 Code Lookup, 2016). Safety status. Pulses 3+ throughout. Delayed healing, rashes, bruising, bleeding or skin discolorations, any changes in lesions or moles, Cough, wheezing, hemoptysis, dyspnea, pneumonia hx, TB, Corrective lenses, blurring, visual changes of any kind, Abdominal pain, N/V/D, constipation, hepatitis, hemorrhoids, eating disorders, ulcers, black tarry stools, Ear pain, hearing loss, ringing in ears, discharge. Hence, quality will consistently be at the top. Educate patient to avoid heavy lifting, and gently reduce a groin hernia when the individual lies supine with hips flexed to relax the abdominal muscles (Cash, 2014). No septal deviation. Baldwin was born in London, and studied chemistry at Imperial College London, where he also did a PhD. It may take up to six weeks for the raash to completely heal. There is tenderness within the left inguinal canal; right inguinal canal normal. Teeth are in good repair. Tactile fremitus equal bilaterally. With an exceptional team of professional academic experts in a wide range of subjects, we can guarantee you an unrivaled quality of custom-written papers. Describe the course of the patients illness, including when it began, character of symptoms, location where the symptoms began, aggravating or alleviating factors; pertinent positives and negatives, other related diseases, past illnesses, surgeries or past diagnostic testing related to present illness. SOAP Note and Differential Diagnoses for iHuman Case. Continue participating in workout regimen. Use this week's iHuman case titled "Jack Baldwin VE" and create a SOAP note with a treatment plan (located at the bottom of the SOAP note. No palpable thrills, lifts, or heaves. Provide a subjective, objective, assessment, and plan (SOAP) note on this patient and your treatment plan using the SOAP note template. Scrotal ultrasound reveals the following: Normal testicular size bilaterally (Fischbach & Dunning, 2014). He states the patin is often as 8 or 10 out of 10 severity. St. Louis, Mo. Teeth are in good repair. Maintains eye contact. Introduction One of the most common ways in wh, In this discussion, we connect the key statements summarizing a firms overall financial health, assets and liabilities, activities, earnings, and disposition or use of earnings. Educate patient to avoid heavy lifting, and gently reduce a groin hernia when the individual lies supine with hips flexed to relax the abdominal muscles (Cash, 2014). No relevant social history; denies use of tobacco, alcohol, or illicit drugs. Add or change photo on IMDbPro Add to list Known for Henry IV: Part 1 8.7 Falstaff Ears: Canals patent. No adnexal masses or tenderness. Bilateral TMs pearly grey with positive light reflex; landmarks easily visualized. They will write your papers from scratch. Flu shot in October 2012 and plans to get the Flu vaccine this year. Watch. Thepain should ease within two to three days. Vesicles may burst and then crust over. All new clients are eligible for 20% off in their first Order. Return to clinic:RTC in one week if pain persists or s/s of infection occur. Tetanus booster vaccine in 2010. This helps overcome occupational hazards brought about by fatigue. Use this week's iHuman case titled "Jack Baldwin VE" and create a SOAP note with a treatment plan (located at the bottom of the SOAP note. Normal penile shaft, without lesions or discharge. Skin is brown, warm, dry, clean and intact. Rash present to mid-back on the right side at location of 6th rib, bright red, linear form, with vesicular type blisters present. Skin is brown, warm, dry, clean and intact. He is not in distress. Environmental hazards:Patient denies any environmental hazards. A:P / 2:1. Ears: Canals patent. Provide a subjective, objective, assessment, and plan (SOAP) note on this patient and your treatment plan using the SOAP note template. It is also important to avoid people with weakened immune systems. Jack Baldwin VE iHuman Episodic SOAP Note and Differential Diagnoses Examples Provide a reference for your treatment plan (in APA format). Step 2 Faculty and administrators can reduce grading, and simply . The reference may come from a journal, a book, etc. Primary care: A collaborative practice (4rd ed.). Jack Baldwin VE iHuman Episodic SOAP Note and Differential Diagnoses Examples Cite. Environmental hazards:Patient denies any environmental hazards. Our price ranges from $8-$14 per page. Surgery is an effective treatment, laparoscopy or through an open procedure or mesh repair depending the size of the hernia, and the onset of strangulation. It should be surgical intervention if patient get strangulated hernias (Cash, 2014). No thyromegaly or nodules. Eyes: PERRLA. Support-Chat with us today! A paper on History will only be handled by a writer who is trained in that field. Psychiatric: Alert and oriented to person only. Resonance noted to all fields with percussion. On physical exam, she has an elevated BMI, is tearful, and is noted to have acne, striae, and acanthosis. Right side normal. Patient is appropriately dressed and cooperative in regards to all aspects of the examination. Patients states he now feels a constant sharp, burning pain in the area. You would not leave these in an official SOAP note. It is possible to have shingles flair up again in the future. Approximately 7 inches in length. NSG 6020 Week 9 Discussion.docx South University assessment NSG 6020 - Fall 2019 . The reference may come from a journal, a book, etc. Patient has been controlling pain with Tylenol 650 mg PO and he states it helps moderately. You can protect your immune system with a healthy lifestyle, and keeping your stress at manageable levels can reduce your chances of getting shingles and other. They have also lived in Seneca Falls, NY and Descanso, CA. Skin: Warm, diaphoresis, (-) Delayed healing, (-) rashes, (-) bruising, (-) bleeding or skin discolorations, (-)any changes in lesions or moles No. Include three differential diagnoses and support your diagnoses with supporting literature. HEENT: Head is normocephalic, atraumatic and without lesions; hair evenly distributed. EOMs intact. Material from the iHuman cases may be present in the quizzes, the midterm exam, and the final exam. ORDER A CUSTOM-WRITTEN, PLAGIARISM-FREE PAPER HERE, Provide a subjective, objective, assessment, and plan (SOAP) note on this patient and your treatment plan using the SOAP note template. Gastrointestinal: Abdomen flat; BS hyper active in all 4 quadrants. The post iHuman case titled Jack Baldwin VE appeared first on Homework Gig. Alert and oriented. Nose: Nasal mucosa pink; normal turbinates. Nose: Nasal mucosa pink; normal turbinates. Note: For purposes of this sample SOAP note comments on what is required for each section have been left in place. S1, S2 with regular rate and rhythm. This can cause changes in a person's behavior, movement . HIV status, bruising, blood transfusion hx, night sweats, swollen glands, increase thirst, increase hunger, cold or heat intolerance, Depression, anxiety, sleeping difficulties, suicidal ideation/attempts, previous dx. Jack Baldwin VE iHuman Episodic SOAP Note and Differential Diagnoses Examples. Safety status. Teeth are in good repair. Chronic Illnesses/Major traumas:Patient has a significant history for hypertensionChronic Health Problems: Immunizations:Up to date on all immunizations. The HPI is one of them. Provide a subjective, objective, assessment, and plan (SOAP) note on this patient and your treatment plan using the SOAP note template. Complains fo generalized malaise. Capillary refill 2 seconds. Blisters intact, no exudate or crusting present. Breast is free from masses or tenderness, no discharge, no dimpling, wrinkling or discoloration of the skin. Breast is free from masses or tenderness, no discharge, no dimpling, wrinkling or discoloration of the skin. Posture erect. Pulses 3+ throughout. Philadelphia, PA: F.A. Touch device users, explore by touch or with swipe gestures. Buttaro, T., Trybulski, J., Bailey,P., & Sandberg-Cook, J. Overwise, PRN. He is not in distress. Dressed in clean slacks, shirt and coat. Jack Baldwin VE iHuman Episodic SOAP Note and Differential Diagnoses Examples SOAP Note and Differential Diagnoses for iHuman Case. Pharynx is nonerythematous and without exudate. Flu shot in October 2012 and plans to get the Flu vaccine this year. No vulvar lesions noted. Pinterest. He makes eye contact and responds to questions appropriately. Respiratory: Symmetric chest wall. Have you every been told that you have: Diabetes, HTN, peptic ulcer disease, asthma, lung disease, heart disease, cancer, TB, thyroid problems or kidney disease or psychiatric diagnosis.. Non-medication treatments:Maintain adequate hydratin b continuing to drink 68 glasses of water a day. He makes eye contact and responds to questions appropriately. Maintains eye contact. Vesicles may burst and then crust over. A small speculum was inserted; vaginal walls are pink and well rugated; no lesions noted. We will write your work from scratch and ensure it's plagiarism-free, you just submit the completed work. Jack Baldwin is a 50-year-old male with health conditions that relate to hypertension. (2016). Height: 60 Pulse: 130bmp (tachycardia) RR: 18bpm, oxygen saturation is 98%, RA. Oral mucosa pink and moist. Evidenced by Inguinal or scrotal nonreducible mass with severe pain, vomiting, and constipation and scrotal ultrasound result (Fischbach & Dunning, 2014). The other symptoms include urethral discharge, dysuria, hematuria (Cash, 2014), Kidney Stone: Add Ct scan to determine the stone size, if the test of urine positive for renal calculi. The HPI is one of them. Full ROM; no cervical lymphadenopathy; no occipital nodes. EOMs intact. [South University]. I love going to iHuman. One of the questions that should have been asked is the social relationship of the patient. Does your mother, father or siblings have any medical or psychiatric illnesses? Provide a reference for your treatment plan (in APA format). Truss can be used to groin hernias. Uterus is antevert and positioned behind a slightly distended bladder; no fullness, masses, or tenderness. The left groin region is visibly swollen and indurated to palpation. Jack Baldwin VE iHuman Episodic SOAP Note, Permalink:https://nursingbay.com/jack-baldwin-ve-agnoses-examples/, Jack Baldwin VE iHuman Episodic SOAP Note and Differential Diagnoses Examples. Hernia inguinal K40 (ICD-10 Code Lookup, 2016). He complains of generalized malaise and reports a low grade fever no higher than 100.1 F. The pain worsens with touch and movement. Head is normocephalic, atraumatic and without lesions; hair evenly distributed. Postoperative evaluation for hernia recurrences as needed (Cash, 2014). (2014). Patient reports having chicken pox when he was age 5. Advise that a person sho has never had chicken pox may contract chicken pos by exposure to the shingles rash. Retrieved from https://digitalbookshelf.southuniversity.edu/#/books/9780826168757/. Delayed healing, rashes, bruising, bleeding or skin discolorations, any changes in lesions or moles, Cough, wheezing, hemoptysis, dyspnea, pneumonia hx, TB, Corrective lenses, blurring, visual changes of any kind, Abdominal pain, N/V/D, constipation, hepatitis, hemorrhoids, eating disorders, ulcers, black tarry stools, Ear pain, hearing loss, ringing in ears, discharge. Housing: Condominium Occupation: Accountant Tobacco use: Smokes 1 ppd; Alcohol: 1 to 2 drinks/day; History of: narcotic abuse (Percocet) Sexual history: Monogamous Jack Baldwin VE iHuman Episodic SOAP Note and Differential Diagnoses Examples, General(-) Fatigue, (-) weight loss, (-) chills, (-) fever, (-) night sweats, (-) change in energy level, Skin(-) delayed healing, (-) rashes, (-) bruising, (-) bleeding or skin discolorations, (-) any changes in lesions or moles, Eyes(-) Corrective lenses, (-) blurring,(-) change in vision Ears(-) ear pain, (-) hearing loss, (-) dischargeNose/Mouth, Throat(-) Sinus problems, (-) dysphagia, (-) nose bleeds or discharge, (-)dental disease, (-) hoarseness, (-) throat pain, Heme/Lymph/Endo (-)HIV, (-) blood transfusion hx(-), cold intolerance, (-) bruising, (-) night sweats, (-) increase hunger/thirst, Cardiovascular(-) chest pain, (-) palpitations, (-) edema, (-) PND, (-) orthopnea Respiratory(-) cough, (-) wheeze, (-) hemoptysis, (-) dyspnea, (-) pneumonia hx, (-) TB, Gastrointestinal(-) Abdominal pain, (+) Nausea, (+) vomiting, diarrhea(-), (-) constipation, (-) hepatitis, (-) hemorrhoids, (-)eating disorders, (-) ulcers, (-) black tarry stools, Genitourinary/Gynecological:(-) urgency, (-) frequency, (-) hesitancy, (-) dysuria, (-) hematuria (+) sexual activity, (-) STDS, Rectal Denies any bleeding or pain Musculoskeletal(-) back pain, (-) swelling of joints, (-) fracture historyNeurologicalDenies weakness or numbness, (-) headache, (-) Syncope, (-) seizures, (-) transient paralysis, (-) weakness, (-) paresthesias, (-) black out spells, Psychiatric(-) depression, (-) anxiety, (-) sleeping difficulties, (-) suicidal ideation/attempts, (-) previous dx, Weight: 180.0 lbs.
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