Be on schedule.Score better.

EN

Analyze the subjective portion of the note

Objective:

  • VS: Temp 98.6; BP 120/86; RR 16; P 92; HT 5’10”; WT 169lbs
  • Heart: RRR, no murmurs
  • Lungs: CTA, chest wall symmetrical
  • Genital: Normal female hair pattern distribution; no masses or swelling. Urethral meatus intact without erythema or discharge. Perineum intact with a healed episiotomy scar present. Vaginal mucosa pink and moist with rugae present, pos for firm, round, small, painless ulcer noted on external labia
  • Abd: soft, normoactive bowel sounds, neg rebound, neg murphy’s, neg McBurney
  • Diagnostics: HSV specimen obtained

Assessment:

  • Chancre
  • PLAN: This section is not required for the assignments in this course (NURS 6512) but will be required for future courses.

To prepare:

With regard to the SOAP note case study provided:

  • Review this week’s Learning Resources, and consider the insights they provide about the case study.
  • Consider what history would be necessary to collect from the patient in the case study.
  • Consider what physical exams and diagnostic tests would be appropriate to gather more information about the patient’s condition. How would the results be used to make a diagnosis?
  • Identify at least five possible conditions that may be considered in a differential diagnosis for the patient.

To complete:

Refer to Chapter 5 of the Sullivan text. Analyze the SOAP note case study.  Using evidence based resources, answer the following questions and support your answers using current evidence from the literature.

  • Analyze the subjective portion of the note. List additional information that should be included in the documentation.
  • Analyze the objective portion of the note. List additional information that should be included in the documentation.
  • Is the assessment supported by the subjective and objective information? Why or Why not?
  • Would diagnostics be appropriate for this case and how would the results be used to make a diagnosis?
  • Would you reject/accept the current diagnosis? Why or why not? Identify three possible conditions that may be considered as a differential diagnosis for this patient. Explain your reasoning using at least 3 different references from current evidence based literature.

Assignment 1: Assessing the Genitalia and Rectum

Assignment 1: Assessing the Genitalia and Rectum

Table of Contents

[display_short_calculator]

Latest Reviews

Impressed with the sample above? Wait there is more

Related Questions

Protecting Businesses using Technology

 What are the costs and benefits of developing cybersecurity programs in businesses? “While you’re thinking through this article, consider the constant yin and yang that

Segmentation is critical for businesses

Marketing,” 2010) Segmentation is critical for businesses because it helps them identify segments of the population that buy their products. Typically, these segments are relatively

How do nurses develop best practice?

Please Check the Competencies: Overview   Write 3–5 pages in which you describe a nursing informatics best practices policy for effective and safe data use

Speculate on the possible direction

i)    A classic case-control study was conducted in 1966 to compare the coffee drinking habits of pancreatic cancer patients with the coffee drinking habits of

High Gothic Cathedrals in France.

 For this first writing assignment, you will research the last of the great High Gothic cathedrals in France, specifically the Cathedral of Amiens. There are

New questions

Predictors of harmful

Predictors of harmful stress for one individual may have beneficial effects for another. The Achilles heel phenomenon suggests that people break down at their weakest

Othello Essay

Type of paper Essay (Any Type) Subject Literature Number of pages 5 Format of citation MLA Number of cited resources  2 Type of service  Writing

Don't Let Questions or Concerns Hold You Back - Make a Free Inquiry Now!