Cite all sources using APA format. You would not leave these in an official SOAP note. Symmetric chest wall. Ears: Canals patent. Reason given by the patient for seeking medical care in quotes. He states the patin is often as 8 or 10 out of 10 severity. A:P / 2:1. 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). 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 palpable thrills, lifts, or heaves. Abdomen soft, non-tender. He was on trial at Gillingham and impressed Gills boss Andy Hessenthaler after a season with . Truss can be used to groin hernias. Continue participating in workout regimen. Dressed in clean slacks, shirt and coat. Skin is brown, warm, dry, clean and intact. Jack Baldwin VE iHuman Episodic SOAP Note and Differential Diagnoses Examples, Chief Complaint (CC): severe left groin pain for 6 hours. : Mosby/Elsevier. 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. Testicular torsion: sudden onset of pain which is exquisite tenderness; and a high-riding, horizontally displaced testis (Goolsby & Grubbs, 2015). Head is normocephalic, atraumatic and without lesions; hair evenly distributed. No extra sounds, clicks, rubs or murmurs. Abdomen soft, non-tender. Nose: Nasal mucosa pink; normal turbinates. Ears: Canals patent. Teeth are in good repair. Rectal as appropriate: no evidence of hemorrhoids, fissures, bleeding or masses. External genitalia reveals coarse pubic hair in normal distribution; skin color is consistent with general pigmentation. Philadelphia, PA: F.A. No vulvar 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). Safety status. Dressed in clean slacks, shirt and coat. NSG 6020 Week 9 Discussion.docx South University assessment NSG 6020 - Fall 2019 . Patients states he now feels a constant sharp, burning pain in the area. Reason given by the patient for seeking medical care in quotes. Urgency, frequency burning, change in color of urine. Buttaro, T., Trybulski, J., Bailey,P., & Sandberg-Cook, J. Thepain should ease within two to three days. The HPI is one of them. Cardiovascular: Tachycardia, S1, S2 with regular rate and rhythm. No adnexal masses or tenderness. Confidential- We never share or sell your personal information to third parties. Psychiatric: Alert and oriented to person only. 34 year old white male who appears his stated age. 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. HPI: Mr. Baldwin is a 50-year old male who experienced the sudden onset of severe pain in his left groin radiating to his testicles after moving a refrigerator 6 hours ago. It is possible to have shingles flair up again in the future. The solution of Jack Baldwin V5 i-human. Select this result to view Jack M Baldwin's phone number, address, and more. Denies bruising or other abnormalities to skin, hair, or nails. Use this week's iHuman case titled "Jack Baldwin VE" and create a. The testicles are normal in size and nontender to palpation. Consider the following: Tariffs are paid by the citizens of the country, Mean corpuscular hemoglobin concentration (MCHC). 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. Jack is related to James L Baldwin and Debbie Stefanko as well as 3 additional people. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins. 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. Home No conjunctival or scleral injection. Maintains eye contact. PMI noted at 5thICS MCL. Jack Baldwin VE iHuman Episodic SOAP Note, Permalink:https://nursingbay.com/jack-baldwin-ve-agnoses-examples/, Jack Baldwin VE iHuman Episodic SOAP Note and Differential Diagnoses Examples. Jack Baldwin VE iHuman Episodic SOAP Note and Differential Diagnoses Examples. 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. (2014). She denies any active suicidal thoughts (i-Human). Scrotal ultrasound reveals the following: Normal testicular size bilaterally (Fischbach & Dunning, 2014). RRR, S1 and S2 present. The physical exam is significant for tachycardia, hypertension, diaphoresis, and severe pain in a swollen left groin. Once youve submitted your writing requests, you can go take a stroll while waiting for our all-star team of writers and editors to submit top quality work. Balance stable; gait normal. Eyes: PERRLA. 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. Denies any heat or cold intolerance, thyroid enlargement or tenderness, unexpected weight changes, or abnormal distribution in body hair. Get your customized and 100% plagiarism-free paper done It is possible to have shingles flair up again in the future. Pulses 3+ throughout. No other lesions, bruises, or suspicious moles present. Slightly somber affect at first, then brighter later. Alert and oriented. Explore. Monitor for s/s of infection (increased redness, fever, pain, or purulent, fould smelling drainage). SOAP Note and Differential Diagnoses for iHuman Case. iHuman case titled "Jack Baldwin VE" QUESTION DESCRIPTION SOAP NOTE AND DIFFERENTIAL DIAGNOSES FOR IHUMAN CASE. Postoperative evaluation for hernia recurrences as needed (Cash, 2014). 34K views 4 years ago i-Human Patients 2.1K views 7 years ago Poets & Quants 431K views 3 years ago Pulmonary. 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. Genitourinary: Bladder is non-distended; no CVA tenderness. Posture erect. No extra sounds, clicks, rubs or murmurs. Table of Content. Fitness: encouraging increasing exercise (Buttaro, Trybulski & Bailey, 2013). It should be surgical intervention if patient get strangulated hernias (Cash, 2014). Advanced assessment: Interpreting findings and formulating differential diagnoses. https://digitalbookshelf.southuniversity.edu/#/books/9780826168757/, Nursing Capstone Project Writing Services, Nursing Annotated Bibliography by Professional, Online Nursing Research Paper writing service, Mean corpuscular hemoglobin concentration (MCHC). Jack Baldwin VE iHuman Episodic SOAP Note and Differential Diagnoses Examples. Jack Baldwin VE iHuman Episodic SOAP Note and Differential . Anyone diagnosed with: lung disease, heart disease, htn, cancer, TB, DM, or kidney disease. Dressed in clean slacks, shirt and coat. 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. 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. Click here for information on how to access and navigate iHuman. Reason given by the patient for seeking medical care in quotes. He states the patin is often as 8 or 10 out of 10 severity. Full ROM seen in all 4 extremities as patient moved about the exam room. 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. Patients states he now feels a constant sharp, burning pain in the area. Neck: Supple. Provide a subjective, objective, assessment, and plan (SOAP) note on this patient and your treatment plan using the SOAP note template. Pulses 3+ throughout. Ticket to Enter Student Guidelines Ticket to Enter for Virtual Simulation IHuman - SCOTT BALDWIN (SEIZURE) 1. Weight change, fatigue, fever, chills, night sweats, energy level, Chest pain, palpitations, PND, orthopnea, edema. He played college football for Centenary in Louisiana and professional football for the New York Yankees, San Francisco 49ers, Buffalo Bills, and Edmonton Eskimos . Teeth are in good repair. They have also lived in Seneca Falls, NY and Descanso, CA. Summetrical thoracis expansion. No extra sounds, clicks, rubs or murmurs. No hepatosplenomegaly. Schedule the patient to return to the office if fever, severe pain, or strangulation happens. Good tone. No conjunctival or scleral injection. General Appearance: A healthy appearing adult male with acute distress. Primary care: A collaborative practice (4rd ed.). 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. ORDER COMPREHENSIVE SOLUTION PAPERS ON Jack Baldwin VE iHuman Episodic SOAP Note, https://digitalbookshelf.southuniversity.edu/#/books/9780826168757/, Mean corpuscular hemoglobin concentration (MCHC). Jack Baldwin VE iHuman Episodic SOAP Note and Differential Diagnoses Examples SOAP Note and Differential Diagnoses for iHuman Case. Overwise, PRN. No palpable thrills, lifts, or heaves. Good tone. With such a system, you neednt worry about the quality of work. Capillary refill 2 seconds. Balance stable; gait normal.Psychiatric: Alert and oriented to person only. Nutrition: recommending better choices when eats out (Buttaro, Trybulski & Bailey, 2013). 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. 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. S1, S2 with regular rate and rhythm. They also have unrivalled skill in writing language be it UK English or USA English considering that they are native English speakers. We dont just employ writers, we hire professionals. Complains of sharp, burning pain to the area. General Appearance: A healthy appearing adult male with acute distress. Ovaries are non-palpable. Respirations regular and easy; lungs clear to auscultation bilaterally. General Appearance: A healthy appearing adult male with acute distress. Rash present to mid-back on the right side at location of 6thrib, bright red, linear form, with vesicular type blisters present. This week, complete the iHuman case titled " Buddy (Theodore, Jr.) VE ." Abdomen soft, non-tender. You can contact our live agent via WhatsApp +1(209)962-2652, Reflective Analysis: Risk Management and the Role of Managed Care. Healthy appearing adult female in no acute distress. Pulses 3+ throughout. Does your mother, father or siblings have any medical or psychiatric illnesses? In CMS.gov. Abdomen obese; BS active in all 4 quadrants. Uterus is antevert and positioned behind a slightly distended bladder; no fullness, masses, or tenderness. Provide a subjective, objective, assessment, and plan (SOAP) note on this patient and your treatment plan using the SOAP note template. Hence, quality will consistently be at the top. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins. Ears: Canals patent. My brother brought me here to get me help because I was going through a tough time. Height: 60 Pulse: 130bmp (tachycardia) RR: 18bpm, oxygen saturation is 98%, RA. Capillary refill 2 seconds. Neck: Supple. 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 . That's called the flank, right? No relevant social history; denies use of tobacco, alcohol, or illicit drugs. No S3, S4, murmurs, or bruits noted. Fitness: encouraging increasing exercise (Buttaro, Trybulski & Bailey, 2013). You will get it few hours before your set deadline. Maintains eye contact. Eyes: PERRLA. Cervix is pink. 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 Include three differential diagnoses and support your diagnoses with supporting literature. No hepatosplenomegaly. Ovaries are non-palpable. Alert and oriented. Enhanced Investments - Financial Portal - EnInvs Edexcel AS/A Level History, Paper 1&2 R. Rees, J. Shuter . S1, S2 with regular rate and rhythm. Pharynx is nonerythematous and without exudate. Avoid contact with infants, children, pregnant women, and adults who have never had chicken pox, until blisters are completely dry. 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). Jack Baldwin VE iHuman Episodic SOAP Note and Differential Diagnoses Examples. 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.. Alert and oriented; answers questions appropriately. Testicular torsion: sudden onset of pain which is exquisite tenderness; and a high-riding, horizontally displaced testis (Goolsby & Grubbs, 2015). Slightly somber affect at first, then brighter later. Hernia inguinal K40 (ICD-10 Code Lookup, 2016). Complains fo generalized malaise. Recommend smoking cessation patient not ready (Buttaro, Trybulski & Bailey, 2013). (Male: both testes palpable, no masses or lesions, no hernia, no uretheral discharge. 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. Flu shot in October 2012 and plans to get the Flu vaccine this year. Jack Baldwin VE iHuman Episodic SOAP Note and Differential Diagnoses Examples. Clear to auscultation with no . Speech is soft, though clear and of normal rate and cadence; answers questions appropriately. Complains fo generalized malaise. Flu shot in October 2012 and plans to get the Flu vaccine this year. Posture erect. Sms or Whatsapp only : US: +1(516)494-0538, Jack Baldwin VE iHuman Episodic SOAP Note, Permalink:https://collepals.com/jack-baldwin-ve-agnoses-examples/, Jack Baldwin VE iHuman Episodic SOAP Note and Differential Diagnoses Examples. Nose: Nasal mucosa pink; normal turbinates. Capillary refill 2 seconds. To make an Order you only need to click ORDER NOW and we will direct you to our Order Page. Environmental hazards:Patient denies any environmental hazards. Full ROM seen in all 4 extremities as patient moved about the exam room. Anyone diagnosed with: lung disease, heart disease, htn, cancer, TB, DM, or kidney disease. College pals.com Privacy Policy 2010-2018, ORDER COMPREHENSIVE SOLUTION PAPERS ON Jack Baldwin VE iHuman Episodic SOAP Note, Write a 3-page briefing of potential factors and issues associated with four types of business entities in the context of U.S. contract law. Students can be assigned cases individually, in a lecture, a flipped classroom or in a team-based learning environment. <br> <br>Prostrate is smooth, non-tender and free from nodules, is of normal size, sphincter tone is firm. Cervix is pink. Patient has been controlling pain with Tylenol 650 mg PO and he states it helps moderately. Dressed in clean slacks, shirt and coat. Pharynx is nonerythematous and without exudate. i-Human Patients 82 subscribers Web demo of i-Human Patients Case Player in HD. No septal deviation. Oral mucosa pink and moist. Oral mucosa pink and moist. Speech is soft, though clear and of normal rate and cadence; cant answer questions appropriately. 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. No edema. No nail pitting or clubbing. No vulvar lesions noted. In 1967, he moved to . Nose: Nasal mucosa pink; normal turbinates. PMI noted at 5thICS MCL. Complains of sharp, burning pain to the area. 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. 34 year old male presents to office with a linear vesicular rash to the right side of his back. A small speculum was inserted; vaginal walls are pink and well rugated; no lesions noted. Respirations regular and easy; lungs clear to auscultation bilaterally. HEENT: Head is normocephalic, atraumatic and without lesions; hair evenly distributed. IHuman - SCOTT BALDWIN (SEIZURE) - $14.49 Add to cart. Approximately 7 inches in length. Balance stable; gait normal. Safety status. Musculoskeletal: Full ROM seen in all 4 extremities as patient moved about the exam room. As in all assignments, cite your sources when applicable throughout your SOAP note and provide references for the citations in APA format at the end of your SOAP note. BMI: 24.4 Temp: 99 (Oral)BP: 170/94. Prostrate is smooth, non-tender and free from nodules, is of normal size, sphincter tone is firm. (2014). Postoperative evaluation for hernia recurrences as needed (Cash, 2014). HPI: Mr. Baldwin is a 50-year old male who experienced the sudden onset of severe pain in his left groin radiating to his testicles after moving a refrigerator 6 hours ago. Skin is brown, warm, dry, clean and intact. 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. Resonance noted to all fields with percussion. We respect your money and most importantly your trust in us. Please note that your SOAP note has several areas that have required information. Monitor for s/s of infection (increased redness, fever, pain, or purulent, fould smelling drainage). We have writers spread into all fields including but not limited to Philosophy, Economics, Business, Medicine, Nursing, Education, Technology, Tourism and Travels, Leadership, History, Poverty, Marketing, Climate Change, Social Justice, Chemistry, Mathematics, Literature, Accounting and Political Science. Popular books for Arts, Humanities and Cultures. Remember to keep the patients identity private; use the minimal amount of information possible to get the idea across. 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. Jack Baldwin VE iHuman Episodic SOAP Note and Differential Diagnoses Examples. There is tenderness within the left inguinal canal; right inguinal canal normal. In 1965, he was appointed assistant lecturer at Imperial College. He is well-groomed, fit, and cheerful, he is alert and orientedx4, can answer any question by himself.. . Abdomen obese; BS active in all 4 quadrants. Remember to keep the patients identity private; use the minimal amount of information possible to get the idea across. Seizures are sudden, uncontrolled electrical disturbance in the brain. He states the patin is often as 8 or 10 out of 10 severity. Just request for our write my paper service, and we\'ll match you with the best essay writer in your subject! Balance stable; gait normal. Quality- We are experienced and have access to ample research materials. Include a discount code if you have one. 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. Capillary refill 2 seconds. Ears: Canals patent. Our writers will help you write all your homework. Rash present to mid-back on the right side at location of 6th rib, bright red, linear form, with vesicular type blisters present. On-Time Delivery! Davis Company. Height: 60 Pulse: 130bmp (tachycardia) RR: 18bpm, oxygen saturation is 98%, RA. Pricing and Discounts ORDER A CUSTOM-WRITTEN, PLAGIARISM-FREE PAPER HERE Provide a reference for your treatment plan (in APA format). Fitness: encouraging increasing exercise (Buttaro, Trybulski & Bailey, 2013). No edema. Discuss the pathophysiology of this disease process/condition. It is also important to avoid people with weakened immune systems. Alert and oriented X3, well groomed, well nourished and hydrated. Safety meaures:Patient states I always wear my seatbelt. Provide a reference for your treatment plan (in APA format). Sir Jack E. Baldwin FRS (August 8, 1938- January 4, 2020) Born in London, Baldwin conducted his undergraduate and graduate studies at Imperial College with Nobel Laureate Sir Derek Barton (who described him as his best student), and received his PhD in 1964. Does your mother, father or siblings have any medical or psychiatric illnesses? Who cant do that? Pulses 3+ throughout. Cash, J. C. (2014). Exercise and leisure:Walks occasionally for exercise. With an exceptional team of professional academic experts in a wide range of subjects, we can guarantee you an unrivaled quality of custom-written papers. Complains of rash to middle of right side of back. SOAP Note and Differential Diagnoses for iHuman Case. Once done with writing your paper we will upload it to your account on our website and also forward a copy to your email. All new clients are eligible for 20% off in their first Order. At the risk of sounding immodest, we must point out that we have an elite team of writers. Cancer-screening modalities for gender/age: prostate exam (Buttaro, Trybulski & Bailey, 2013). No septal deviation. Family Practice Guidelines, Third Edition, 3rd Edition. You would not leave these in an official SOAP note. Otherwise no complaints at this time. Faculty and administrators can reduce grading, and simply . ). Respirations regular and easy; lungs clear to auscultation bilaterally. 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. Good tone. 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. The scrotum is swollen on left side. Include three differential diagnoses and support your diagnoses with supporting literature. No conjunctival or scleral injection. Summetrical thoracis expansion. Eyes: PERRLA. The HPI is one of them. It may take up to six weeks for the raash to completely heal. 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. Nose: Nasal mucosa pink; normal turbinates. 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. Buttaro, T., Trybulski, J., Bailey,P., & Sandberg-Cook, J. This helps overcome occupational hazards brought about by fatigue.
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