Professional Documents
Culture Documents
2017 November
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Question
Week 1 - Assignment 2 Discussion
You are a family nurse practitioner working in a community health center. The patient you
are about to see is a 3 month old natal female infant for a well-baby check. The child has
just been adopted. The mother stays at home with the baby and the father works outside
the home. They are covered by private health insurance through the father’s work. The
parents own their own home in a suburban area, neither smoke, and they have one
dog.Answer the following questions using course resources (texts) and two other evidence
based sources (current guidelines and/or scholarly articles that are within a 3-5 year time
frame).
What are the components of a well-child check for this 3-month old infant?
Write an educational intervention plan for the parents. What are you going to teach the
parents about their baby?
When completing a physical exam for this baby, what would be of particular focus and why?
Week 2 - Assignment 1 Discussion
SOAP Note
Each week, you are required to enter your patient encounters into eMedley. Your faculty will
be checking to ensure you are seeing the right number and mix of patients for a good
learning experience. You will also need to include a minimum of one complete SOAP note
using the SOAP Note template.
SOAP Note: Choose one patient from an area of weakness identified from the Week 1 Pre-
Predictor Exam and submit a SOAP note of this patient. Remember to remove all forms of
patient identification from the SOAP note format. Provide a reference (s) for the differential
diagnosis and treatment plan in APA format. The reference should be within a 3-5 year time
frame and come from a textbook, guideline,or currently published peer reviwed journal
article.
Submission Details:
By Wednesday, October 18, 2017, enter your patient encounters into eMedley and complete
at least one SOAP note in the template provided.
Include the reference number from eMedley in your document.
Submit your SOAP note into the discussion area below by Sunday, October 15, 2017 along
with clinical insights about your case.
Respond to two peers with a substantial response that includes supportive references by
Wednesday, October 18, 2017.
Week 3 - Assignment 1 Discussion
Assignment 1: SOAP Note
Each week, you are required to enter your patient encounters into eMedley. Your faculty will
be checking to ensure you are seeing the right number and mix of patients for a good
learning experience. You will also need to include a minimum of one complete SOAP note
using the SOAP Note template.
SOAP Note: Choose one patient from an area of weakness identified from the Week 1 Pre-
Predictor Exam and submit a SOAP note of this patient. Remember to remove all forms of
patient identification from the SOAP note format. Provide a reference (s) for the differential
diagnosis and treatment plan in APA format. The reference should be within a 3-5 year time
frame and come from a textbook, guideline, or currently published peer reviewed journal
article.
Submission Details:
By Wednesday, October 25, 2017, enter your patient encounters into eMedley and complete
at least one SOAP note in the template provided.
Include the reference number from eMedley in your document.
Submit your SOAP note into the discussion area below by Sunday, October 22, 2017 along
with clinical insights about your case.
Respond to two peers with a substantial response that includes supportive references by
Wednesday, October 25, 2017.
SUBJECTIVE
CC:
Reason given by the patient for seeking medical care “in quotes”
HPI:
PMH
Allergies:
Hospitalizations/Surgeries
“Have you ever been told that you have diabetes, HTN, peptic ulcer
disease, asthma, lung disease, heart disease, cancer, TB, thyroid
problems, kidney problems, or psychiatric diagnosis?”
Family History
Social History
ROS
General Cardiovascular
Weight change, fatigue, fever, chills, night sweats, and energy level Chest pain, palpitations, PND,
orthopnea, and edema
Skin Respiratory
Delayed healing, rashes, bruising, bleeding or skin discolorations, Cough, wheezing, hemoptysis,
and any changes in lesions or moles dyspnea, pneumonia hx, and TB
Eyes Gastrointestinal
Corrective lenses, blurring, and visual changes of any kind Abdominal pain, N/V/D,
constipation, hepatitis,
hemorrhoids, eating disorders,
ulcers, and black, tarry stools
Ears Genitourinary/Gynecological
Ear pain, hearing loss, ringing in ears, and discharge Urgency, frequency burning,
change in color of urine.
Nose/Mouth/Throat Musculoskeletal
Sinus problems, dysphagia, nose bleeds or discharge, dental Back pain, joint swelling, stiffness
disease, hoarseness, and throat pain or pain, fracture hx, and
osteoporosis
Heme/Lymph/Endo Psychiatric
HIV status, bruising, blood transfusion hx, night sweats, swollen Depression, anxiety, sleeping
glands, increase thirst, increase hunger, and cold or heat intolerance difficulties, suicidal
ideation/attempts, and previous
dx
OBJECTIVE
General Appearance
Skin
HEENT
Cardiovascular
S1, S2 with regular rate and rhythm. No extra sounds, clicks, rubs,
or murmurs. Capillary refills two seconds. Pulses 3+ throughout. No
edema.
Respiratory
Gastrointestinal
Breast
Genitourinary
Musculoskeletal
Full ROM seen in all four extremities as the patient moved about the
exam room.
Neurological
Speech clear. Good tone. Posture erect. Balance stable; gait normal.
Psychiatric
Lab Tests
Urinalysis—pending
Urine culture—pending
Wet prep—pending
Special Tests
Diagnosis
o Plan:
Further testing