Kibata

Sign In

Our Services

Get 15% Discount on your First Order

Order Now
[rank_math_breadcrumb]

Rh week 1 case study

Case study 

Instructions

· Review the following case study.

· Construct a subjective data set for the case study on the provided SOAP note template from the information provided.  

· Structure the subjective data set on the SOAP note template in the format provided in your lecture materials.  

· Submit the Word file containing your subjective data set on the SOAP note template into Canvas.

NU610 Unit 1 Case Study
A 19-year-old female presents with a complaint of headaches frequently. She reports that she has had
them since she was a teenager, but they have become more debilitating recently. The episodes occur
once or twice a month and last for up to 2 days. The pain begins in the right temple or the back of the
right eye and spreads to the entire scalp over a few hours. She describes the pain as a sharp, throbbing
sensation that gradually worsens and is associated with sever nausea. Several factors aggravate the pain
including loud noises and movement. She has taken several over the counter medication like naproxen
and acetaminophen for the pain but the only thing that makes it better is going to sleep in a dark quiet
room. Reports no drug allergies but has seasonal and allergies to pet dander. A thorough history reveals
her mother suffers from migraines. Last menses 4 weeks ago, is sexually active uses condoms. Currently
a freshman in college. Denies alcohol, illicit drug and tobacco use. Last health visit was over the
Summer, up to date on health maintenance for her age. She denies fever, chills, night sweats or neck
stiffness. She denies visual changes other than photophobia. She denies chest pain, palpitations,
shortness of breath or cough. She denies abdominal pain, has some nausea with the headaches but no
vomiting. Denies numbness, tingling, weakness or changes in mood. Vital signs: temperature 98.5, BP
112/70, HR 62, RR 17, 99% RA, Ht. 68 inches, Wt. 151 lbs. Alert and oriented to self, place, time and
situation. Appears stated age with skin warm and dry. Normocephalic, PERRL, TM gray with adequate
conf of light bilaterally, no tenderness over sinuses. Mucous membranes pink and dry. No palpable
masses, adenopathy or thyroid enlargement. Regular heart rate and rhythm without murmurs. No
edema. Lungs clear bilaterally, no use of accessory muscles. Soft, non-tender, non-distended abdomen
with normoactive bowel sounds. Normal visual acuity using Snellen chart 20/20, face symmetrical with
symmetrical smile and puffing out cheeks. Weber and Rinne test performed with normal bone and air
conduction. Palate and uvula at rest are free of fasciculations and symmetry noted at test and when pt.
says “ah.” Positive gag reflex. Shrug shoulders spontaneously and against resistance, hypoglossal nerve
intact. Muscle tone inspected, palpated without atrophy and strength 5/5. Bicep, patellar and Achilles
reflexes 2+ bilaterally with negative Babinski. Able to distinguish light and deep touch. Able to
complete heel to shin, gait steady.

SOAP Note _______
NU___:_________
Herzing University
Name:_________________________
Typhon Encounter #: _____________________
Comprehensive:____Focused:____
S: SUBJECTIVE DATA
CC: What are they being seen for? This is the reason that the patient sought
care, stated in their own words/words of their caregiver, or paraphrased.
HPI: Use the “OLDCART” approach for collecting data and documenting
findings. [O=onset, L=location, D=duration, C=characteristics,
A=associated/aggravating factors, R=relieving factors, T=treatment,
S=summary]
PMH: This should include past illness/diagnosis, conditions, traumas,
hospitalizations, and surgical history. Include dates if possible.
ALLERGIES State the offending medication/food and the reactions.
MEDICATIONS Names, dosages, and routes of administration along with indication of
use.
SH Related to the problem, educational level/literacy, smoking, alcohol,
drugs, HIV risk, sexually active, caffeine, work and other stressors.
Cultural and spiritual beliefs that impact health and illness. Financial
resources.
FH Use terms like maternal, paternal, and the diseases along with the ages
they were deceased or diagnosed if known.
HEALTH
PROMOTION &
MAINTENANCE
Required for all SOAP notes: Immunizations, exercise, diet, etc.
Remember to use the United States Clinical Preventative Services Task
Force (USPSTF) for age-appropriate indicators. This should reflect what
the patient is presently doing regarding the guidelines. Other wellness
visits including but not limited to dental and eye exams.
Constitutional
Head
Eyes
Ears, Nose, Mouth, Throat
Neck
Cardiovascular/Peripheral
Vascular
Respiratory
Breast
ROS
(put N/A in sections
not completed day of
exam)
Gastrointestinal

SOAP Note _______
NU___:_________
Herzing University
Name:_________________________
Typhon Encounter #: _____________________
Comprehensive:____Focused:____
Genitourinary
Musculoskeletal
Integumentary
Neurological
Psychiatric (screening tools: Ex:
PHQ-9, MMSE, GAD-7)
Endocrine
Hematologic/Lymphatic
Allergic/Immunologic
Other
O: OBJECTIVE DATA
HR: RR: BP: Temp:
SpO2%: Ht: Wt: BMI:
VITALS:
Age: LMP: PAIN:
General Appearance
Head
Eyes
ENT, Mouth
Neck
Cardiovascular/Peripheral Vascular
Respiratory
Breast
Gastrointestinal
Genitourinary Male
• External Exam
• Internal Exam
Genitourinary Female
• External Exam
• Internal Exam
Musculoskeletal
Integumentary
Neurological
Psychiatric
Endocrine
PHYSICAL
EXAM
(Pertinent data
related to
presenting
problem or
visit type. Put
N/A in sections
not completed
day of exam)
Hematologic/Lymphatic

SOAP Note _______
NU___:_________
Herzing University
Name:_________________________
Typhon Encounter #: _____________________
Comprehensive:____Focused:____
Allergic/Immunologic
Other
A: ASSESSMENT AND DIAGNOSIS
DIAGNOSIS ICD-10 CODES
1.
2.
PRIORITIZE
DIAGNOSIS
3.
VISIT CODES CPT BILLING CODES
POC TESTINGDIAGNOSTICS
TESTS REVIEWED
P: PLAN
ACTIONS 1. Diagnosis:
Diagnostics Order: labs, diagnostics testing (tests that you planned
for/ordered during the encounter that you plan to review/evaluate
relative to your work up for the patient’s chief complaint.)
Therapeutic: changes in meds, skin care, counseling, include full
prescribing information for any pharmacologic interventions
including quantity and number of refills for any new or refilled
medications. (Ex: Amoxicillin 500mg, PO, q12h, x 7 days, #14, no
refills)
Education: information clients need in order to address their health
problems. Include follow-up care. Anticipatory guidance and
counseling.

SOAP Note _______
NU___:_________
Herzing University
Name:_________________________
Typhon Encounter #: _____________________
Comprehensive:____Focused:____
Consultation/Collaboration: referrals or consult while in clinic with
another provider. If no referral made was there a possible referral
you could make and why? Advance care planning.
2. Diagnosis:
Diagnostics Order:
Therapeutic:
Education:
Consultation/Collaboration:
3. Diagnosis:
Diagnostics Order:
Therapeutic:
Education:
Consultation/Collaboration:
PREVENTITIVE
(Used for
comprehensive exams)
Enter Guidance, Health Promotion, and/or Disease Prevention for
patient, family, and/or caregiver.
FOLLOW UP

Share This Post

Email
WhatsApp
Facebook
Twitter
LinkedIn
Pinterest
Reddit

Order a Similar Paper and get 15% Discount on your First Order

Order Now

Related Questions

unit 1 discussion

see attached Discussion Overview · Please describe your experience in supporting clients with mental health concerns. · Provide a description of your current position · What mental health condition do you find challenging to work with? Explain why. · What are the current barriers to promoting mental health? What health

Benchmark – Patient’s Spiritual Needs: Case Analysis

For this final assignment, you will be tasked to review your work in the Topic 3 case study and continue to analyze the case to best determine spiritual care interventions throughout their plan of care. In particular, the focus will be on the Christian application of the four principles, as

Patient Safety Culture

Use attachment Culture of Patient Safety Case Studies The purpose of this assignment is to create a culture of patient safety using information and communication technologies and informatic processes to deliver safe nursing care while promoting health. Part 1: Creating a Culture of Patient Safety Instructions: Please review the following

1 response DB Week 1

see attachment  Denise, a 19-year-old female presents to the clinic for an annual physical exam. She is G0P0, and presents with irregular menses only occurring every 3-4months apart within the past 2 years. She is sexually active and only using condoms occasionally. She is not on any other birth control

Week 1 DB response 2

see attachment  Subjective CC: Follow-up for abnormal Pap smear showing HSIL and positive high-risk HPV. HPI: Ellen is a 35-year-old G1P0 female who presents following an abnormal Pap smear result indicating High-Grade Squamous Intraepithelial Lesion (HSIL) with positive high-risk HPV. She reports no symptoms and states the abnormal results were

Mit

Review the following case study. Construct a subjective data set for the case study on the provided SOAP note template from the information provided.   Structure the subjective data set on the SOAP note template in the format provided in your lecture materials.  

Journal Entry

Journal Entry Critical reflection of your growth and development during your practicum experience in a clinical setting has the benefit of helping you to identify opportunities for improvement in your clinical skills, while also recognizing your strengths and successes.  Use this Journal to reflect on your clinical strengths and opportunities

evaluation

Level 1: Clinical Performance Evaluation- ADNG 1200 Clinical I · Student will complete a self-evaluation of each student learning outcome below using the criteria on the left found under each outcome. Briefly summarize, either in bullet point or paragraph form, your own evaluation of performance in each. Be specific, give

6016 part 2

Prepare an evaluation (5-7 pages) of an existing QI initiative to determine if the initiative is effective. Collapse All Introduction Too often, discussions about quality health care, care costs, and outcome measures take place in isolation—various groups talking among themselves about results and enhancements. Nurses are critical to the delivery

understanding culture bsn assessment 3

Select two artifacts from different cultures that depict a hero and analyze the similarities and differences between the heroic qualities expressed or represented in these artifacts. Other people’s ideas are often better than your own. Find a group of people who challenge and inspire you, spend a lot of time

role of the Psychiatric Mental Health Nurse Practitioner

  This week’s discussion is a two folds discussion. First, explain the role of the Psychiatric Mental Health Nurse Practitioner as it relates to the scope of psychotherapy. Second, explain how this week’s discussion aligns with the following APNA standard: Standard 5G: Therapeutic Relationship: Psychiatric-mental health registered nurse uses therapeutic relationship

6020 part 1

In a 5-6 page paper, identify risks of potential health problems related to infection control during a disaster or catastrophic event. Collapse All Introduction Think about a recent or past disaster or catastrophic event that occurred in your local community. Imagine you’ve been invited to participate in your local community

Death and Dying: Case Analysis

The practice of health care providers at all levels brings you into contact with people from a variety of faiths. This calls for basic knowledge and understanding of different faith expressions. No matter what someone’s worldview is, death and dying is a difficult experience whether emotions are expressed or not.

Week 1 re

#1 An action item that resonated with my role as a clinical nurse coordinator is the ability to enhance quantitative reasoning. It is important to show that “the most successful population health initiatives have demonstrated their effectiveness through distinctive quality improvement methods that combine thinking about assessment, outcomes, and costs

Assessment

See the attached file for instructions The final deliverable for this assessment will be a PowerPoint presentation with detailed presenter’s notes representing the material you would deliver at an in-service session to raise awareness of your chosen safety improvement initiative focusing on a specific patient safety issue and to explain

WK 11 RESPOND 2 EPID

Infectious Disease and Natural Disaster The earthquake that struck Haiti in 2010 was one of the worst natural disasters in history. According to Peranteau et al. (2010): Immediately after the earthquake the need so vastly outstripped the resources that patients generally lacked basic identifiers and medical records […] Treatment plans

WK 11 RESP 2 DATA

 Ethical Considerations   Throughout this course, you will have explored the importance of research, the impact of research, and the different types of research. During our final week, you will explore the importance of ethical considerations in research. In this Discussion, you will focus on a specific study to explore ethics

Ethical Health Promotion

Please see attached for instructions Ethical Health Promotion Instruction 2- to 3-Page Paper Details: Find a scholarly, peer-reviewed article no more than four years old that discusses an ethical health promotion-related issue. Use the WCU library databases to search for appropriate articles. In your paper: · Briefly summarize the presented issue.