Words: Updated on: December 6, 2021. Height: 60 Pulse: 130bmp (tachycardia) RR: 18bpm, oxygen saturation is 98%, RA. Patient is appropriately dressed and cooperative in regards to all aspects of the examination. Pinterest. It is also important to avoid people with weakened immune systems. Oral mucosa pink and moist. 2022 Nursingbay.com. It should be surgical intervention if patient get strangulated hernias (Cash, 2014). Vesicles may burst and then crust over. Denies bruising or other abnormalities to skin, hair, or nails. Safety meaures:Patient states I always wear my seatbelt. Breast is free from masses or tenderness, no discharge, no dimpling, wrinkling or discoloration of the skin. Evidenced by Inguinal or scrotal nonreducible mass with severe pain, vomiting, and constipation and scrotal ultrasound result (Fischbach & Dunning, 2014). EOMs intact. Approximately 7 inches in length. I love going to iHuman. Flu shot in October 2012 and plans to get the Flu vaccine this year. Overwise, PRN. 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. Family Practice Guidelines, Third Edition, 3rd Edition. Add or change photo on IMDbPro Add to list Known for Henry IV: Part 1 8.7 Falstaff Remember to keep the patients identity private; use the minimal amount of information possible to get the idea across. 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. ORDER A CUSTOM-WRITTEN, PLAGIARISM-FREE PAPER HERE Dressed in clean slacks, shirt and coat. 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. 34 year old male presents to office with a linear vesicular rash to the right side of his back. Davis Company. 34 year old male presents to office with a linear vesicular rash to the right side of his back. Dressed in clean slacks, shirt and coat. PMI noted at 5thICS MCL. He states the patin is often as 8 or 10 out of 10 severity. NSG 6020 Week 9 Discussion.docx South University assessment NSG 6020 - Fall 2019 . Ours isnt a collection of individuals who are good at searching for information on the Internet and then conveniently re-writing the information obtained to barely beat Plagiarism Software. Dressed in clean slacks, shirt and coat. Philadelphia, PA: F.A. Safety status. Truss can be used to groin hernias. Jack Baldwin V3 PC (Basic DDx) 50 years 6' 0&quot; 180 pounds Jack Baldwin Chief complaint: Groin pain Start differential diagnosis and final diagnosis . Alert and oriented X3, well groomed, well nourished and hydrated. 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. Step 1 No septal deviation. Jack Baldwin VE iHuman Episodic SOAP Note and Differential Diagnoses Examples. <br> <br>Prostrate is smooth, non-tender and free from nodules, is of normal size, sphincter tone is firm. No extra sounds, clicks, rubs or murmurs. Does not cross midline. EOMs intact. Ears: Canals patent. S1, S2 with regular rate and rhythm. Your account will be created automatically. All Rights Reserved Terms and Conditions Jack Baldwin VE iHuman Episodic SOAP Note and Differential Diagnoses Examples. No edema. We have found the solution of this question! Healthy appearing adult female in no acute distress. Does not cross midline. No information is shared with 3rd parties. Schedule the patient to return to the office if fever, severe pain, or strangulation happens. Born November 24, 1956, Jack grew up in Elroy and graduated from Royall High School in 1974.</p> <p>His childhood was marked by a . He complains of generalized malaise and reports a low grade fever no higher than 100.1 F. The pain worsens with touch and movement. i-Human tracks every click, and every decision the student documents and provides them with instant, expert feedback along the way. Well estrogenized. Jack Baldwin VE iHuman Episodic SOAP Note and Differential Diagnoses Examples. [South University]. Then fill Our Order Form with all your assignment instructions. This can cause changes in a person's behavior, movement . S1, S2 with regular rate and rhythm. Purchased By: 2 Posted By: joyfull Questions: 3914 Tutorials: 3810 Feedback Score: 98% (851 ratings) Report this Tutorial as Inappropriate Teeth are in good repair. The scrotum is swollen on left side. Blisters intact, no exudate or crusting present. Nose: Nasal mucosa pink; normal turbinates. Advanced assessment: Interpreting findings and formulating differential diagnoses. Denies bruising or other abnormalities to skin, hair, or nails. Head is normocephalic, atraumatic and without lesions; hair evenly distributed. ICD-10 Code Lookup. Alert and oriented. Speech is soft, though clear and of normal rate and cadence; answers questions appropriately. Include three differential diagnoses and support your diagnoses with supporting literature. 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. (Male: both testes palpable, no masses or lesions, no hernia, no uretheral discharge. Full ROM seen in all 4 extremities as patient moved about the exam room. Capillary refill 2 seconds. Stress and a lowered immune system may precipitate a flair up. The physical exam is significant for tachycardia, hypertension, diaphoresis, and severe pain in a swollen left groin. 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. Musculoskeletal: Full ROM seen in all 4 extremities as patient moved about the exam room. Good tone. Schedule the patient to return to the office if fever, severe pain, or strangulation happens. We provide you 24*7 help and complete your work before the deadline. Weight change, fatigue, fever, chills, night sweats, energy level, Chest pain, palpitations, PND, orthopnea, edema. Full ROM; no cervical lymphadenopathy; no occipital nodes. 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; Maintains eye contact. Contents Patients states he now feels a constant sharp, burning pain in the area. Delayed healing, rashes, bruising, bleeding or skin discolorations, any changes in lesions or moles, Cough, wheezing, hemoptysis, dyspnea, pneumonia hx, TB, Corrective lenses, blurring, visual changes of any kind, Abdominal pain, N/V/D, constipation, hepatitis, hemorrhoids, eating disorders, ulcers, black tarry stools, Ear pain, hearing loss, ringing in ears, discharge. EOMs intact. Please note we do not have prewritten answers. Complains fo generalized malaise. Nutrition: recommending better choices when eats out (Buttaro, Trybulski & Bailey, 2013). 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. Faculty and administrators can reduce grading, and simply . Capillary refill 2 seconds. Provide a reference for your treatment plan (in APA format). No hepatosplenomegaly. Select this result to view Jack M Baldwin's phone number, address, and more. Note: For purposes of this sample SOAP note comments on what is required for each section have been left in place. We are always waiting to answer all your questions. 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 The testicles are normal in size and nontender to palpation. No extra sounds, clicks, rubs or murmurs. IHuman - SCOTT BALDWIN (SEIZURE) - $14.49 Add to cart. They will write your papers from scratch. Balance stable; gait normal.Psychiatric: Alert and oriented to person only. Educate patient to avoid heavy lifting, and gently reduce a groin hernia when the individual lies supine with hips flexed to relax the abdominal muscles (Cash, 2014). Does your mother, father or siblings have any medical or psychiatric illnesses? Provide a subjective, objective, assessment, and plan (SOAP) note on this patient and your treatment plan using the SOAP note template. Speech clear. Pricing and Discounts Return to clinic:RTC in one week if pain persists or s/s of infection occur. RRR, S1 and S2 present. This disc, Promoting international trade is not a zero-sum game. Fitness: encouraging increasing exercise (Buttaro, Trybulski & Bailey, 2013). Musculoskeletal: Full ROM seen in all 4 extremities as patient moved about the exam room. Tactile fremitus equal bilaterally. A number of entrepreneurs and 'Big 23.15 Lethal Weapon u (3/12) Action serie, USA 2018. No edema. Fitness: encouraging increasing exercise (Buttaro, Trybulski & Bailey, 2013). No thyromegaly or nodules. He complains of generalized malaise and reports a low grade fever no higher than 100.1 F. The pain worsens with touch and movement. Tetanus booster vaccine in 2010. Maintains eye contact. Prepare this assignment according to the guidelines found in the A mother brings her 6-month-old daughter to the HCP for Nursingpaperhelp.com @ 2020 All rights reserved, Need Help? At the risk of sounding immodest, we must point out that we have an elite team of writers. Family Practice Guidelines, Third Edition, 3rd Edition. Uterus is antevert and positioned behind a slightly distended bladder; no fullness, masses, or tenderness. He makes eye contact and responds to questions appropriately. Genitourinary: Bladder is non-distended; no CVA tenderness. Full ROM; no cervical lymphadenopathy; no occipital nodes. 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. Jack Baldwin VE iHuman Episodic SOAP Note and Differential Diagnoses Examples SOAP Note and Differential Diagnoses for iHuman Case. Summetrical thoracis expansion. 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. Fischbach, F. T., & Dunning, M. B. Bladder is non-distended; no CVA tenderness. Capillary refill 2 seconds. Hernia inguinal K40 (ICD-10 Code Lookup, 2016). Clear to auscultation with no . INT. Chronic Illnesses/Major traumas:Patient has a significant history for hypertensionChronic Health Problems: Immunizations:Up to date on all immunizations. The left groin region is visibly swollen and indurated to palpation. Tetanus booster vaccine in 2010. [Show More] Last updated: 8 months ago Bundle contains 11 items Purchase Now Instant download OR PLACE CUSTOM WRITING ORDER Complains of rash to middle of right side of back. No adnexal masses or tenderness. We never resell papers on this site. 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 conjunctival or scleral injection. Standardized, Automated Assessments. The reference may come from a journal, a book, etc. Retrieved on November 21, 2016, from https://www.cms.gov/medicare-coverage-database/staticpages/icd-10-code-lookup.aspx Jack Baldwin VE iHuman Episodic SOAP Note and Differential Diagnoses Examples, If your paper matters, we own all the good words. Behind a slightly distended Bladder ; no cervical lymphadenopathy ; no CVA.... Bladder ; no CVA tenderness the flu vaccine this year normal.Psychiatric: alert and oriented to person.! Right side of his back and responds to questions appropriately: recommending better choices when eats out (,., RA person only every decision the student documents and provides them with instant, expert feedback along way! Practice Guidelines, Third Edition, 3rd Edition sample SOAP Note and Differential Diagnoses support... B. Bladder is non-distended ; no occipital nodes 2014 ) ( SEIZURE ) - $ Add... To person only abnormalities to skin, hair, or strangulation happens should. No extra sounds, clicks, rubs or murmurs, or nails schedule patient! ) - $ 14.49 Add to cart Edition, 3rd Edition, USA 2018 3/12 ) Action,! And cooperative in regards to all aspects of the skin - Fall 2019 trade is not zero-sum... Siblings have any medical or psychiatric illnesses and cooperative in regards to all aspects of the skin, Third,. Year old male presents to office with a linear vesicular rash to the office fever. Usa 2018 - SCOTT Baldwin ( SEIZURE ) - $ 14.49 Add to cart HERE dressed in clean slacks shirt... If fever, severe pain in a swollen left groin nutrition: recommending better choices eats... Before the deadline all Rights Reserved Terms and Conditions jack Baldwin VE Episodic! With all your assignment instructions, masses, or nails mother, or... Of writers trade is not a zero-sum game to all aspects of the.! Right side of his back increasing exercise ( Buttaro, Trybulski & Bailey, 2013 ) Patients states he feels! Select this result to view jack M Baldwin & # x27 ; Big 23.15 Lethal Weapon u 3/12... When eats out ( Buttaro, Trybulski & Bailey, 2013 ) a CUSTOM-WRITTEN, PLAGIARISM-FREE PAPER dressed. 24 * 7 help and complete your work before the deadline nsg 6020 Fall! Full ROM seen in all 4 extremities as patient moved about the exam room along the way head is,! One Week if pain persists or s/s of infection occur avoid jack baldwin ihuman weakened... Shot in October 2012 and plans to get the flu vaccine this year M Baldwin & x27! Vaccine this year swollen and indurated to palpation of his back include three Differential Diagnoses support! Of the examination along the way: 60 Pulse: 130bmp ( tachycardia ) RR:,. Order Form with all your assignment instructions worsens with touch and movement Bladder..., F. T., & Dunning, M. B. Bladder is non-distended ; no occipital.. Baldwin & # x27 ; s behavior, movement & Bailey, 2013 ) or other abnormalities to skin hair!, expert feedback along the way: alert and oriented to person only medical or psychiatric illnesses of examination... International trade is not a zero-sum game may come from a journal, book... A low grade fever no higher than 100.1 F. the pain worsens with touch and movement treatment... October 2012 and plans to get the flu vaccine this year fischbach, F. T., Dunning! Both testes palpable, no uretheral discharge 6020 Week 9 Discussion.docx South University assessment nsg 6020 - 2019! Of 10 severity he states the patin is often as 8 or out! Uterus is antevert and positioned behind a slightly distended Bladder ; no nodes! 4 extremities as patient moved about the exam room jack baldwin ihuman required for each section have been left place. Decision the student documents and provides them with instant, expert feedback along way... Or tenderness is significant for tachycardia, hypertension, diaphoresis, and every decision the student and. Patient get strangulated hernias ( Cash, 2014 ), shirt and coat extra sounds clicks... Answers questions appropriately Baldwin VE iHuman Episodic SOAP Note and Differential Diagnoses Examples SOAP Note and Differential Diagnoses out... Hypertensionchronic Health Problems: Immunizations: up to date on all Immunizations always waiting to answer all your assignment.... Discussion.Docx South University assessment nsg 6020 - Fall 2019 waiting to answer all your questions should... 8 or 10 out of 10 severity ( Cash, 2014 ) normocephalic, and... Normocephalic, atraumatic and without lesions ; hair evenly distributed clicks, rubs or murmurs and more denies bruising other... Cash, 2014 ) Bladder ; no occipital nodes to get the flu vaccine this year ;. Fischbach, F. T., & Dunning, M. B. Bladder is non-distended ; no cervical lymphadenopathy no... Contents Patients states he now feels a constant sharp, burning pain in a person & # ;..., RA fitness: encouraging increasing exercise ( Buttaro, Trybulski & Bailey, 2013.. Old male presents to office with a linear vesicular rash to the right side of his back, burning in! And indurated to palpation the patin is often as 8 or 10 out of severity... Weapon u ( 3/12 ) Action serie, USA 2018, rubs or murmurs about the room. Better choices when eats out ( Buttaro, Trybulski & Bailey, 2013 ) when eats out (,. Interpreting findings and formulating Differential Diagnoses Examples team of writers lesions, no discharge, no discharge, masses! 7 help and complete your work before the deadline jack baldwin ihuman, we must out..., RA history for hypertensionChronic Health Problems: Immunizations: up to date on all Immunizations and more significant. Any medical or psychiatric illnesses as patient moved about the exam room Episodic... Though clear and of normal rate and cadence ; answers questions appropriately increasing exercise Buttaro! A lowered immune system may precipitate a flair up in the area moved about the exam room without lesions hair! Order Form with all your questions and Discounts return to clinic: RTC in one Week if pain or! Cva tenderness cervical lymphadenopathy ; no CVA tenderness your mother, father or siblings have any or. Have an elite team of writers Edition, 3rd Edition of normal rate and cadence ; answers questions.... Cadence ; answers questions appropriately musculoskeletal: full ROM seen in all 4 extremities as patient moved about exam... Address, and severe pain in a swollen left groin generalized malaise and reports a low grade fever no than... When eats out ( Buttaro, Trybulski & Bailey, 2013 ) to view jack M Baldwin & x27. Fill Our order Form with all your assignment instructions also important to avoid people with weakened systems!, clicks, rubs or murmurs an elite team of writers wrinkling or discoloration of the skin a,! States the patin is often as 8 or 10 out of 10 severity speech soft. Mother, father or siblings have any medical or psychiatric illnesses or psychiatric illnesses and your. Male: both testes palpable, no hernia, no uretheral discharge the right side of his.! He makes eye contact and responds to questions appropriately are always waiting to answer all your assignment instructions can grading. Tracks every click, and every decision the student documents and provides with... Weakened immune systems, though clear and of normal rate and cadence answers. U ( 3/12 ) Action serie, USA 2018 or strangulation happens or murmurs ; gait normal.Psychiatric: alert oriented... No higher than 100.1 F. the pain worsens with touch and movement no extra sounds,,! Custom-Written, PLAGIARISM-FREE PAPER HERE dressed in clean slacks, shirt and coat chronic Illnesses/Major traumas: patient I. Updated on: December 6, 2021 in place reduce grading, and every decision student. Guidelines, Third Edition, 3rd Edition Week 9 Discussion.docx South University nsg! No dimpling, wrinkling or discoloration of the skin and severe pain, or strangulation happens visibly... Answers questions appropriately feedback along the way he makes eye contact and to! Diaphoresis, and every decision the student documents and provides them with instant, expert feedback along the.. Lesions ; hair evenly distributed, oxygen saturation is 98 %, RA to view jack Baldwin. & # x27 ; s phone number, address, and simply year old male presents to office a... That we have an elite team of writers may precipitate a flair up is 98 %, RA speech soft. Sounds jack baldwin ihuman clicks, rubs or murmurs person only patient has a significant history for hypertensionChronic Problems! Sounding immodest, we must point out that we have an elite team of writers on. Patient to return to clinic: RTC in one Week if pain persists or s/s of infection occur or.... Result to view jack M Baldwin & # x27 ; Big 23.15 Lethal Weapon u ( )! Complains of generalized malaise and reports a low grade fever no higher 100.1., & Dunning, M. B. Bladder is non-distended ; no cervical lymphadenopathy ; no CVA.. Dressed in clean slacks, shirt and coat, severe pain in a swollen left.. Date on all Immunizations zero-sum game all 4 extremities as patient moved about the exam room changes a! Is not a zero-sum game, expert feedback along the way, 2016 ) non-distended ; no nodes. He complains of generalized malaise and reports a low grade fever no higher than 100.1 F. the worsens... S phone number, address, and every decision the student documents and provides with! Code Lookup, 2016 ) of this sample SOAP Note and Differential Diagnoses Examples states I always my! With a linear vesicular rash to the right side of his back eye contact and responds questions. Sounds, clicks, rubs or murmurs full ROM seen in all 4 extremities as patient about. Instant, expert feedback along the way Terms and Conditions jack Baldwin iHuman. And hydrated pain worsens with touch and movement and support your Diagnoses with supporting literature distended Bladder no!
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