The reference may come from a journal, a book, etc. Schedule the patient to return to the office if fever, severe pain, or strangulation happens. Reports pain and rash on the right side of back. Chronic Illnesses/Major traumas:Patient has a significant history for hypertensionChronic Health Problems: Immunizations:Up to date on all immunizations. Jack Baldwin VE iHuman Episodic SOAP Note and Differential . Nose: Nasal mucosa pink; normal turbinates. If it meets your requirements, approve and download it. With such a system, you neednt worry about the quality of work. Rash present to mid-back on the right side at location of 6th rib, bright red, linear form, with vesicular type blisters present. 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. He complains of generalized malaise and reports a low grade fever no higher than 100.1 F. The pain worsens with touch and movement. Include three differential diagnoses and support your diagnoses with supporting literature. All new clients are eligible for 20% off in their first Order. RRR, S1 and S2 present. The third result is Jack Lee Baldwin age 60s in El Cajon, CA in the El Cajon neighborhood. Bilateral TMs pearly grey with positive light reflex; landmarks easily visualized. Advanced health assessment NSG 6020 Health Science Science Nursing Answer & Explanation Unlock full access to Course Hero Explore over 16 million step-by-step answers from our library Get answer Maintains eye contact. Head is normocephalic, atraumatic and without lesions; hair evenly distributed. No extra sounds, clicks, rubs or murmurs. Denies bruising or other abnormalities to skin, hair, or nails. (2014). No septal deviation. 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. 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. 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. Environmental hazards:Patient denies any environmental hazards. Goolsby, M. J., & Grubbs, L. (2015). Jack Baldwin VE iHuman Episodic SOAP Note and Differential Diagnoses Examples. Teeth are in good repair. Angela Cortez iHuman Case study Example Essay. Fischbach, F. T., & Dunning, M. B. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins. Capillary refill 2 seconds. PMI noted at 5th ICS MCL. Denies bruising or other abnormalities to skin, hair, or nails. [Show More] Last updated: 8 months ago Bundle contains 11 items Purchase Now Instant download OR PLACE CUSTOM WRITING ORDER Contents Full ROM; no cervical lymphadenopathy; no occipital nodes. Summetrical thoracis expansion. Rectal as appropriate: no evidence of hemorrhoids, fissures, bleeding or masses. He was supervised by Derek Barton, a pioneer of conformational analysis the idea that the. My brother brought me here to get me help because I was going through a tough time. Psychiatric: Alert and oriented to person only. Right side normal. No vulvar lesions noted. No hepatosplenomegaly. Advise that a person sho has never had chicken pox may contract chicken pos by exposure to the shingles rash. Our price ranges from $8-$14 per page. Balance stable; gait normal.Psychiatric: Alert and oriented to person only. External genitalia reveals coarse pubic hair in normal distribution; skin color is consistent with general pigmentation.No uretheral discharge. Exercise and leisure: Walks occasionally for exercise. No extra sounds, clicks, rubs or murmurs. Eyes: PERRLA. Jack Baldwin VE iHuman Episodic SOAP Note and Differential Diagnoses Examples. Nose: Nasal mucosa pink; normal turbinates. Nutrition: recommending better choices when eats out (Buttaro, Trybulski & Bailey, 2013). No conjunctival or scleral injection. 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. Then fill Our Order Form with all your assignment instructions. 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. No septal deviation. (Rectal as appropriate: no evidence of hemorrhoids, fissures, bleeding or massesMales: prostrate is smooth, non-tender and free from nodules, is of normal size, sphincter tone is firm). Alvin Stafford V5 i-human; Florence Blackman V5 i-human; Susan White V5 i-human; Jerome Cauthen V5 i-human; AssignmentePortfolio Clinical Judgment and plan for life-long learning; Clear to auscultation with no adventitous sounds bilaterally. Jack Baldwin V3 PC (Basic DDx) 50 years 6' 0" 180 pounds Jack Baldwin Chief complaint: Groin pain Start differential diagnosis and final diagnosis . Alert and oriented X3, well groomed, well nourished and hydrated. Cardiovascular: Tachycardia, S1, S2 with regular rate and rhythm. No relevant social history; denies use of tobacco, alcohol, or illicit drugs. EOMs intact. A:P / 2:1. External genitalia reveals coarse pubic hair in normal distribution; skin color is consistent with general pigmentation. No conjunctival or scleral injection. No extra sounds, clicks, rubs or murmurs. No edema. Hernia inguinal K40 (ICD-10 Code Lookup, 2016). No other lesions, bruises, or suspicious moles present. A small speculum was inserted; vaginal walls are pink and well rugated; no lesions noted. (Rectal as appropriate: no evidence of hemorrhoids, fissures, bleeding or massesMales: prostrate is smooth, non-tender and free from nodules, is of normal size, sphincter tone is firm). It may take up to six weeks for the raash to completely heal. Register . <br> <br>Prostrate is smooth, non-tender and free from nodules, is of normal size, sphincter tone is firm. Height: 60 Pulse: 130bmp (tachycardia) RR: 18bpm, oxygen saturation is 98%, RA. Abdomen soft, non-tender. Neck: Supple. I know that normal is used in chartingbut you are learning and so you are required to do the ideal and the ideal is describing what you see and completing a total ROS on every patient. 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. No palpable thrills, lifts, or heaves. There is tenderness within the left inguinal canal; right inguinal canal normal. Buttaro, T., Trybulski, J., Bailey,P., & Sandberg-Cook, J. Click here for information on how to access and navigate iHuman. 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.. SOAP Note and Differential Diagnoses for iHuman Case. Anyone diagnosed with: lung disease, heart disease, htn, cancer, TB, DM, or kidney disease. PMI noted at 5thICS MCL. ). Fitness: encouraging increasing exercise (Buttaro, Trybulski & Bailey, 2013). Alert and oriented; answers questions appropriately. Jack Baldwin VE iHuman Episodic SOAP Note and Differential Diagnoses Examples, o 1- Herpes zoster without mention of complication (053.9) o 2- Rash and other nonspecific skin eruption (782.1) o 3- Other malaise and fatigue (780.79), Presumptive Diagnosis o 1- Herpes zoster without mention of complication (053.9), Diagnois:Herpes zoster without mention of complication (053.9), Medication: Valtrex 1000 mg PO q8h X 7 days, Education: Continue using Tylenol 650 mg PO to manage pain. Complains of rash to middle of right side of back. It is also important to avoid people with weakened immune systems. Get your customized and 100% plagiarism-free paper done 34 year old white male who appears his stated age. A:P / 2:1. Davis Company. Recommend smoking cessation patient not ready (Buttaro, Trybulski & Bailey, 2013). All Rights Reserved Terms and Conditions Safety status. S1, S2 with regular rate and rhythm. Dressed in clean slacks, shirt and coat. (2013). HEENT: Head is normocephalic, atraumatic and without lesions; hair evenly distributed. Rash present to mid-back on the right side at location of 6thrib, bright red, linear form, with vesicular type blisters present. " I came to iHuman because I was homeless and I was new to the city. Posture erect. 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. Nose: Nasal mucosa pink; normal turbinates. Reason given by the patient for seeking medical care in quotes. Epididymitis: fever, Swelling and tenderness of the scrotum (usually located on one side), patient may get relief with elevation of scrotum, which is positive Prehns sign. To make an Order you only need to click ORDER NOW and we will direct you to our Order Page. Philadelphia, PA: F.A. Speech is soft, though clear and of normal rate and cadence; answers questions appropriately. Name:Jack Baldwin Date:March 23, 2017 Time: 11:45 AM Age:50 years Sex:Male SUBJECTIVE CC: "The patient complains of experiencing left groin pain." "The patient is experiencing testicle pain of around 5 out of 10 tearing superficial and profound." "When the patient bends the situation worsens with vomiting been experienced." Pharynx is nonerythematous and without exudate. Skin is brown, warm, dry, clean and intact. Neck: Supple. Right side normal. Abdomen soft, non-tender. Monitor for s/s of infection (increased redness, fever, pain, or purulent, fould smelling drainage). Capillary refill 2 seconds. Does not cross midline. Non-medication treatments:Maintain adequate hydratin b continuing to drink 68 glasses of water a day. Provide a reference for your treatment plan (in APA format). No conjunctival or scleral injection. Jack Baldwin VE iHuman Episodic SOAP Note and Differential Diagnoses Examples, Chief Complaint (CC): severe left groin pain for 6 hours. 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. Oral mucosa pink and moist. 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. iHuman case titled "Jack Baldwin VE" - EssayBark -Excellent Writing Services iHuman case titled "Jack Baldwin VE" December 16, 2017 admin Sample Services All types of Essays Research Papers Case Studies Dissertation & Thesis Services Editing Services Math/Physics/Economics/Statistics Problems Tricky Questions Many more Free Service Features Is it Safe to use our services? No S3, S4, murmurs, or bruits noted. Posture erect. No thyromegaly or nodules. The physical exam is significant for tachycardia, hypertension, diaphoresis, and severe pain in a swollen left groin. [South University]. Speech clear. Getting your paper done is easy when you know the right people. Good tone. Avoid contact with infants, children, pregnant women, and adults who have never had chicken pox, until blisters are completely dry. If you are short of Budget, contact our Live Support for a Discount Code. The left groin region is visibly swollen and indurated to palpation. EOMs intact. Reports pain and rash on the right side of back. Slightly somber affect at first, then brighter later. Standardized, Automated Assessments. In writing, we will be precise and to the point and fill the paper with content as opposed to words aimed at beating the word count. Quality- We are experienced and have access to ample research materials. Full ROM; no cervical lymphadenopathy; no occipital nodes. 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. Denies any heat or cold intolerance, thyroid enlargement or tenderness, unexpected weight changes, or abnormal distribution in body hair. EOMs intact. No hepatosplenomegaly. Discuss the pathophysiology of this disease process/condition. Head is normocephalic, atraumatic and without lesions; hair evenly distributed. Exercise and leisure:Walks occasionally for exercise. Teeth are in good repair. Rectal as appropriate: no evidence of hemorrhoids, fissures, bleeding or masses. He states the patin is often as 8 or 10 out of 10 severity. Patients states he now feels a constant sharp, burning pain in the area. Alert and oriented. 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. Pulses 3+ throughout. Confidential- We never share or sell your personal information to third parties. 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. Provide a reference for your treatment plan (in APA format). Jack is related to James L Baldwin and Debbie Stefanko as well as 3 additional people. In CMS.gov. Philadelphia, PA: F.A. Does not cross midline. Thepain should ease within two to three days. Good tone. i-Human Patients 82 subscribers Web demo of i-Human Patients Case Player in HD. Cervix is pink. Your payment is processed by a secure system. Nose: Nasal mucosa pink; normal turbinates. Jack Baldwin VE iHuman Episodic SOAP Note and Differential Diagnoses Examples SOAP Note and Differential Diagnoses for iHuman Case. In 1965, he was appointed assistant lecturer at Imperial College. 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). Teeth are in good repair. Balance stable; gait normal. Postoperative evaluation for hernia recurrences as needed (Cash, 2014). InCMS.gov. (Male: both testes palpable, no masses or lesions, no hernia, no uretheral discharge. Bladder is non-distended; no CVA tenderness. Shortly strength antfish ftw patetesli tuzlu kek video! Teeth are in good repair. Epididymitis: fever, Swelling and tenderness of the scrotum (usually located on one side), patient may get relief with elevation of scrotum, which is positive Prehns sign. Ovaries are non-palpable. Testicular torsion: sudden onset of pain which is exquisite tenderness; and a high-riding, horizontally displaced testis (Goolsby & Grubbs, 2015). Bilateral TMs pearly grey with positive light reflex; landmarks easily visualized. Thesis papers will only be handled by Masters Degree holders while Dissertations will strictly be handled by PhD holders. Ears: Canals patent. Monitor for s/s of infection (increased redness, fever, pain, or purulent, fould smelling drainage). Popular books for Arts, Humanities and Cultures. 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. No septal deviation. Does your mother, father or siblings have any medical or psychiatric illnesses? Full ROM; no cervical lymphadenopathy; no occipital nodes. Speech is soft, though clear and of normal rate and cadence; cant answer questions appropriately. No thyromegaly or nodules. 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.. Advanced assessment: Interpreting findings and formulating differential diagnoses. Cervix is pink. Summetrical thoracis expansion. Alert and oriented. Blisters intact, no exudate or crusting present. Complains fo generalized malaise.
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