NSG 6020 WK5 Soap Assignment2 – Infectious Colitis or Diverticulitis

NSG 6020 WK5 Soap Assignment2 – Infectious Colitis or Diverticulitis

NSG 6020 WK5 Soap Assignment2 – Infectious Colitis or Diverticulitis

Week 5 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 for NSG 6020 WK5 Soap Assignment2 – Infectious Colitis or Diverticulitis:

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.

SAMPLE SOLUTION

Name:   DR	Date:  09/13/2018		Time:  1630
	Age:  58 years		Sex:  Female
SUBJECTIVE
CC:  “I have nausea, vomiting, abdominal pain, and diarrhea since yesterday.”
HPI:  This is a 58 y/o female with PMH of multiple myeloma, depression, and DVT history presenting with complaint of nausea, vomiting, abdominal pain, and diarrhea. Symptoms started yesterday. She vomited twice today, unable to keep anything down. She has feeling of something stuck at the lower esophagus for quite some time and would like to be scoped during this admission. She has had 8-10 loose bowel movements today, which is watery and associated with abdominal pain. Patient reported abdominal pain as a constant, sharp and cramping in nature, 6/10 in severity, associated with nausea, vomiting, and diarrhea. Patient has been on antiemetic at home that not helpful in relieving the symptom. Patient denies fever, fatigue, wt. loss, dizziness, and blood in stool. She has been admitted multiple times for abdominal pain associated with nausea and diarrhea.
Medications: -Fluoxetine 20mg PO daily for Depression -Docusate Sodium 100mg PO TID for Constipation -Pantoprazole 40mg PO daily for prophylaxis of acute stress ulcer – Bortezomib (Velcade) 1.3 mg/m²/dose IV twice weekly for 2 weeks (days 1, 4, 8, 11) followed by a 10-day rest period (days 12 to 21) for six 3-week cycles; may continue for 8 cycles if response is first seen at cycle 6 -Acyclovir 400 mg PO BID to prevent the herpes zoster in myeloma patient. NSG 6020 WK5 Soap Assignment2 – Infectious Colitis or Diverticulitis. -Morphine SR 30 mg PO BID For pain due to multiple myeloma -Enoxaparin 80 mg SUBQ Q 12 H for prophylaxis of DVT -Loperamide 2 mg PO Q6H PRN for diarrhea -Ondansetron ODT 4 mg PO Q4H PRN for nausea -Promethazine Topical 25 mg topical Q6H PRN for nausea and vomiting   NSG 6020 WK5 Soap Assignment2 – Infectious Colitis or Diverticulitis
PMH -Multiple myeloma -LLE DVT -Depression -Patient denies diabetes, HTN, peptic ulcer disease, asthma, lung disease, heart disease, cancer, TB, thyroid problems or kidney disease or psychiatric diagnosis except depression. Allergies:   NKA Medication Intolerances: no known medication intolerance Chronic Illnesses/Major traumas -Multiple Myeloma -Depression Hospitalizations/Surgeries -Hip replacement on 1/5/18 -Tunneled Catheter placement
Family History Does your mother, father or siblings have any medical or psychiatric illnesses? –Father had diabetes and died due to cancer –Mother diet due to breast caner -Brother died due to cancer -Daughter has diabetes.
Social History Patient denies smoking, alcohol and illicit drugs use
ROS
General WNL. Patient is active, alert, and oriented with no acute distress. Denies weight change, fatigue, fever, chills, night sweats, decrease energy level.		Cardiovascular Denies chest pain, palpitations, PND, orthopnea, edema.
Skin Denies rashes, bruising, bleeding or skin discolorations, itching, dryness, and any changes in lesions or moles.		Respiratory TB test negative. Denies cough, wheezing, hemoptysis, dyspnea, pneumonia.
Eyes Patient uses reading glasses. Denies blurring, diplopia, discharge, vision loss.		Gastrointestinal Reports nausea, vomiting, abdominal pain, and diarrhea. Denies melena, and hematochezia.
Ears Denies ear pain, hearing loss, ringing in ears, discharge. NSG 6020 WK5 Soap Assignment2 – Infectious Colitis or Diverticulitis		Genitourinary/Gynecological -Denies dysuria, hematuria, urgency, frequency, burning sensation, changes in color of urine -Patient is menopausal, sexually active. Denies vaginal discharge, use of contraception, and h/o STDS -Last pap was negative 2 years back -Mammogram done a year ago with normal finding.
Nose/Mouth/Throat Denies sinus problems, dysphagia, nose bleeds or discharge, dental disease, hoarseness, throat pain.		Musculoskeletal Reported back pain on exertion. Denies joint swelling, stiffness or pain, and hx, osteoporosis or fracture.
Breast Denies SBE, lumps, bumps or changes.		Neurological Denies seizures, syncope, and tremors, transient paralysis, weakness, paresthesias, and black out spells
Heme/Lymph/Endo Negative HIV status, denies bruising, blood transfusion hx, night sweats, swollen glands, increase thirst, increase hunger, cold or heat intolerance.		Psychiatric Report depression at the age of 33. Denies confusion, delusions, anxiety, sleeping difficulties, suicidal ideation/attempts.
OBJECTIVE

Weight 168lbs(76.3kg)    BMI  28.8	Temp 36.5	BP  134/85
Height  5.4 feet	Pulse 82	Resp 16
General Appearance Patient is adult female in no acute distress. Alert and oriented; answers questions appropriately.
Skin Skin is white, warm, dry, clean and intact with multiple brown age spots all over her body. No rashes or lesions noted.
HEENT Head is normocephalic, atraumatic and without lesions; hair evenly distributed. Eyes:  PERRLA. EOMs intact. No conjunctival or scleral injection. Ears: Canals patent. Bilateral TMs pearly grey with positive light reflex; landmarks easily visualized. Nose: Nasal mucosa pink; normal turbinates. No septal deviation. Neck: Supple. Full ROM; no cervical lymphadenopathy; no occipital nodes. No thyromegaly or nodules. Oral mucosa pink and moist. Pharynx is non-erythematous and without exudate. Teeth are in good repair.
Cardiovascular S1, S2 with regular rate and rhythm. No extra sounds, clicks, rubs or murmurs. Capillary refill 2 seconds. Pulses 3+ throughout. No edema.

…

NSG 6020 WK5 Soap Assignment2 – Infectious Colitis or Diverticulitis

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.

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.

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 WK5 Soap Assignment2 – Infectious Colitis or Diverticulitis.

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 WK5 Soap Assignment2 – Infectious Colitis or Diverticulitis.

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.