The pain started out mild when I first woke up. Clear to auscultation with no adventitous sounds bilaterally. Our writers have strong academic backgrounds with regards to their areas of writing. 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. Clear to auscultation with no adventitous sounds bilaterally. Bilateral TMs pearly grey with positive light reflex; landmarks easily visualized. Patients states he now feels a constant sharp, burning pain in the area. EOMs intact. You would not leave these in an official SOAP note. This disc, Promoting international trade is not a zero-sum game. 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. Retrieved from https://digitalbookshelf.southuniversity.edu/#/books/9780826168757/. The reference may come from a journal, a book, etc. Chronic Illnesses/Major traumas:Patient has a significant history for hypertensionChronic Health Problems: Immunizations:Up to date on all immunizations. 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. Vesicles may burst and then crust over. Neurological: Speech clear. Patient has been controlling pain with Tylenol 650 mg PO and he states it helps moderately. General Appearance: A healthy appearing adult male with acute distress. This week, complete the iHuman case titled Jack Baldwin VE Complete the iHuman Case study in SOAP format t. To support your SOAP note, use your course and text readings and also use the South University Online Library. 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. Provide a reference for your treatment plan (in APA format). Episodic SOAP Note Sample 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 thyromegaly or nodules. Respiratory: Symmetric chest wall. Pulses 3+ throughout. Reason given by the patient for seeking medical care in quotes. Recommend smoking cessation patient not ready (Buttaro, Trybulski & Bailey, 2013). Treatment of kidney stone includes: pain management such as ibuprofen (Motrin, Advil), Zofran 4mg every 6 hours as needed for controlling nausea/vomiting, helping with passing the stone by using Tamsulosin (Flomax) 0.4mg daily to ease urination (Buttaro, Trybulski & Bailey, 2013). Truss can be used to groin hernias. Your payment is processed by a secure system. (Male: both testes palpable, no masses or lesions, no hernia, no uretheral discharge. 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. Summetrical thoracis expansion. EOMs intact. Full ROM; no cervical lymphadenopathy; no occipital nodes. Get your customized and 100% plagiarism-free paper done Weight change, fatigue, fever, chills, night sweats, energy level, Chest pain, palpitations, PND, orthopnea, edema. Right side normal. Nutrition: recommending better choices when eats out (Buttaro, Trybulski & Bailey, 2013). Then fill Our Order Form with all your assignment instructions. No edema. Approximately 7 inches in length. General Appearance: A healthy appearing adult male with acute distress. The scrotum is swollen on left side. Denies bruising or other abnormalities to skin, hair, or nails. Bilateral TMs pearly grey with positive light reflex; landmarks easily visualized. Capillary refill 2 seconds. Full ROM seen in all 4 extremities as patient moved about the exam room. Resonance noted to all fields with percussion. . Include signs, symptoms, and risk factors. It should be surgical intervention if patient get strangulated hernias (Cash, 2014). Gastrointestinal: Abdomen flat; BS hyper active in all 4 quadrants. No relevant social history; denies use of tobacco, alcohol, or illicit drugs. Dressed in clean slacks, shirt and coat. No nail pitting or clubbing. Upon receiving your paper, review it and if any changes are needed contact us immediately. Add or change photo on IMDbPro Add to list Known for Henry IV: Part 1 8.7 Falstaff Allergies:NKDAMedication Intolerances:None. Advanced assessment: Interpreting findings and formulating differential diagnoses. Cancer-screening modalities for gender/age: prostate exam (Buttaro, Trybulski & Bailey, 2013). He is well-groomed, fit, and cheerful, he is alert and orientedx4, can answer any question by himself.. Tactile fremitus equal bilaterally. Evidenced by Inguinal or scrotal nonreducible mass with severe pain, vomiting, and constipation and scrotal ultrasound result (Fischbach & Dunning, 2014). Right side normal. Jack Baldwin VE iHuman Episodic SOAP Note and Differential Diagnoses Examples. Gastrointestinal: Abdomen flat; BS hyper active in all 4 quadrants. Ears: Canals patent. If it meets your requirements, approve and download it. Postoperative evaluation for hernia recurrences as needed (Cash, 2014). Contraception, sexual activity, STDS Fe: last pap, breast, mammo, menstrual complaints, vaginal discharge, pregnancy hx;Male: prostate, Sinus problems, dysphagia, nose bleeds or discharge, dental disease, hoarseness, throat pain, Back pain, joint swelling, stiffness or pain, fracture hx, osteoporosis, Syncope, seizures, transient paralysis, weakness, paresthesias, black out spells. Weight change, fatigue, fever, chills, night sweats, energy level, Chest pain, palpitations, PND, orthopnea, edema. Hernia inguinal K40 (ICD-10 Code Lookup, 2016). We dont just employ writers, we hire professionals. St. Louis, Mo. Speech clear. Medications: Lisinopril 10mg by mouth daily, Chronic Illness/Major Traumas: Hypertension I10 (ICD-10 Code Lookup, 2016), Kidney stone 20.0 (ICD-10 Code Lookup, 2016), Father: Hypertension, CAD, prostate cancer, Social History Marital status/personal support system: Married x 20 years without kid. Provide a subjective, objective, assessment, and plan (SOAP) note on this patient and your treatment plan using the SOAP note template. Provide a subjective, objective, assessment, and plan (SOAP) note on this patient and your treatment plan using the SOAP note template. The HPI must include: History of Present Illness: O-P-Q-R-S-T questions, Onsetandcircumstances ofOccurrenceof symptom(s), Regionof body andRadiationto other areas, Severityof symptom (0 to 10 scale, if applicable) and associatedSymptoms, Time(duration) andTemporalassociations (what is going on when symptom occurs, In addition, normal is not acceptable you must describe what you are seeing. Fitness: encouraging increasing exercise (Buttaro, Trybulski & Bailey, 2013). Jack Baldwin (V) Actor IMDbPro Starmeter See rank Play trailer 2:14 The Rochdale Pioneers (2012) More at IMDbPro Contact info Agent info Jack Baldwin is known for Henry IV: Part 1 (2012), The Ballad of the Lonely Highwayman (2012) and The Show Must Go Online (2020). 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. Safety meaures: Patient states I always wear my seatbelt. Limit Tylenol to less than 4 g per day. 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.. Abdomen soft, non-tender. 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. Our shift-system also ensures that you get fresh writers each time you send a job. Limit Tylenol to less than 4 g per day. Enhanced Investments - Financial Portal - EnInvs Edexcel AS/A Level History, Paper 1&2 R. Rees, J. Shuter . Return to clinic:RTC in one week if pain persists or s/s of infection occur. Ears: Canals patent. Provide a subjective, objective, assessment, and plan (SOAP) note on this patient and your treatment plan using the SOAP note template. Standardized, Automated Assessments. Does not cross midline. 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. May also place a cool compress to area to ease pain. Stress and a lowered immune system may precipitate a flair up. S1, S2 with regular rate and rhythm. No edema. No edema. Uterus is antevert and positioned behind a slightly distended bladder; no fullness, masses, or tenderness. Blisters intact, no exudate or crusting present. He is not in distress. Genitourinary: Bladder is non-distended; no CVA tenderness. 34 year old male presents to office with a linear vesicular rash to the right side of his back. Breast is free from masses or tenderness, no discharge, no dimpling, wrinkling or discoloration of the skin. Cancer-screening modalities for gender/age: prostate exam (Buttaro, Trybulski & Bailey, 2013). Uterus is antevert and positioned behind a slightly distended bladder; no fullness, masses, or tenderness. i-Human tracks every click, and every decision the student documents and provides them with instant, expert feedback along the way. ). No thyromegaly or nodules. We are always waiting to answer all your questions. The HPI is one of them. (2014). Advise that a person sho has never had chicken pox may contract chicken pos by exposure to the shingles rash. Good tone. Maintains eye contact. Balance stable; gait normal. Good tone. Remember to keep the patients identity private; use the minimal amount of information possible to get the idea across. No conjunctival or scleral injection. Monitor for s/s of infection (increased redness, fever, pain, or purulent, fould smelling drainage). They will always help with everything they can. 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. 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