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Health & Medical Questions Assignment
Health & Medical Questions Assignment
Order ID 53563633773 Type Essay Writer Level Masters Style APA Sources/References 4 Perfect Number of Pages to Order 5-10 Pages Description/Paper Instructions
Health & Medical Questions Assignment
Description
JC
Patient ID: 119531646DOB: 1/4/1981Sex: FAccount No.:
Encounter ID: 262700526Encounter Date: 07/29/2022
Encounter Type: Office Visit
SUBJECTIVE: Chief Complaint: Established care. Physical and well-woman visit History Of Present Illness: The patient is a 41-year-old female who presented for physical and well-woman care. The patient is new in the area, she moves from Michigan state. She has a History of hysterectomy in 2012, Cervix removed Breast implant silicone. Has a mood disorder and is experiencing insomnia, multiple surgery, and digestive issues. The patient was very obese, for which she underwent bariatric surgery. The patient c/o BLE cramping and BUE pain. She needs a psychiatrist in the area. Will need a cardiologist to consult due to a family history of heart disease? Multiple chronic health issues are controlled with medications. Rates bilateral knee pain as 4/10. Medical History: Sphincter of Oddi dysfunction Pancreatitis liver problems Colonoscopy in 2015 Colonoscopy in 1017, repeated in 2020 Sleep apnea Insomnia Depression Panic attacks Mood disorder Surgical History: Pancreatic surgery in 2020 Bariatric surgery in 2018 Hysterectomy in 2012 Cervix removed Breast implant silicone Gynecological History: Hysterectomy in 2012, Cervix removed, Breast implant silicone Family History: Her great grandfather; had colon cancer Father; heart failure Mother; hyperlipidemia and thyroid disease Sibling; Healthy, no health issues Social History:
She drinks I cup of coffee a day a history of 20 years pack smoker-she quit smoking one month ago and started Chantix 1 month ago. The patient denies alcohol intake and the use of illicit drugs. She has used glasses since 2022 and sees an eye doctor. Will need a dentist referral for wisdom teeth removal. She eats 3-5 meals on the go. She sees a psychiatrist in Azle, texas. Smoking Status: Former Smoker Allergies: Trazodone Tramadol Cipro Current Medications: Venlafaxine 150mg ER bid alprazolam 0.25mg daily as needed Hyoscyamine 0.125mg 1 po QID Ondansetron 4mg 1 po as needed Review of System:
Constitutional: Denies weight loss, fever, chills, weakness, or fatigue. Head: Denies headache, lightheadedness, or vertigo Neck: Denies pain, stiffness, or tenderness. Eyes: Denies visual loss, blurred vision, double vision, or yellow sclerae. Ears: Denies hearing loss, tinnitus, pain, vertigo, or use of an assistive hearing device. Nose: Denies sneezing, congestion, runny nose, discharge, obstruction, epistaxis, or sinus issues Mouth: Admit she needs to see the dentist for wisdom teeth removal Throat: Denies sore throat, hoarseness, and dysphagia. Cardiovascular: Denies chest pain, chest pressure, chest discomfort, palpitations, edema, or claudication Respiratory: Denies cough, sputum, SOB, chest congestion, Wheezing, Phlegm, or hemoptysis Gastrointestinal: Admit history Sphincter of Oddi dysfunction, pancreatitis, and liver problems Genitourinary: Denies nocturia, dysuria, incontinence, frequency, urgency, or blood in the urine Musculoskeletal: Admit bilateral knee pain Integumentary(Skin and/or Breast): Denies rash, itching, abnormal lesions or skin problems Neurological: Denies headache, dizziness, syncope, paralysis, ataxia, numbness, or tingling in the extremities. No change in bowel or bladder control. Psychiatric: Admit depression and panic attacks. The patient sees a psychiatrist pcp Endocrine: Admit pancreatitis. Denies Excessive appetite, Excessive thirst, Heat intolerance, Cold intolerance Hematologic/Lymphatic: Denies anemia, bleeding, or bruising. No enlarged nodes. No history of splenectomy Allergic/Immunologic: Denies history of asthma, hives, eczema, itching, nasal congestion, rash, rhinitis, environment
OBJECTIVE: Vital Signs:
Height: 64.00 in Weight: 183.00 lbs BMI: 31.41 Blood Pressure: 114/80 mmHg Temperature: 97.90 F Pulse: 81 beats/min Resp. Rate: 16 Physical Exam:
Constitutional: A 41-year-old well-developed, well-nourished, female who is alert, oriented, and cooperative. She is a good historian and answers questions readily and appropriately. She appears to be in no acute distress. Ears, Nose, Mouth, and Throat: Eyes: PERRLA, EOM’s full, conjunctivae clear, fundi grossly normal, Started using since 2022, ear: EAC’s clear, TM’s normal, Throat: clear, no exudates, Neck: supple, adenopathy, no thyromegaly, no carotid bruits Cardiovascular: Cardiologist consult; family history of heart disease Chest/Breasts: History silicone breast implant Heart: RRR, no murmur, no gallops, or rubs Gastrointestinal (Abdomen): History of Pancreatitis, Genitourinary: no Burning/painful urination, Frequency, Urgency, Night time urination, Blood in the Urine Musculoskeletal: The pat is present with bilateral knee pain Skin: Warm and dry, rashes or abnormal lesions, Extremities: Full ROM without deformities; no clubbing, edema, or cyanosis Neurological/Psychiatric: The patient presented with depression and panic attacks. She sees a psychiatrist
ASSESSMENT: Assessments:
ICD-10 Assessments: Multiple chronic health issues
PLAN: Care Plan: New patient labs work order today. Advise on Mammogram to be done Advise on a healthy diet and exercise to reduce the risk of cardiovascular disease Weight loss to prevent obesity Start gabapentin 600mg po at bedtime Vitamin B12 5000mg Refill needed medications today Cardiologist referral Psychiatrist referral Patient Instructions: Take medication as prescribed
___________________________ Date: _________ [Provider]: Jackie Thomas, APRN Assignment 2: Comprehensive Well-Woman Exam
For a wide variety of medical conditions, early detection of the problem enables timely and more effective treatment. Annual well-woman exams are among the best tools available for health care professionals to identify potential diseases and medical conditions in women.
Advanced nurse practitioners can play an active role in these important visits. This role can include a physical examination as well as collection of details about such factors as nutrition habits, sexual activity, stress, and more. By participating in comprehensive well-woman exams, advanced nurse practitioners can help patients engage in preventative health.
Photo Credit: Teodor Lazarev / Adobe Stock
For this Assignment, you will complete your well-woman exam using a focused note format in which you will gather patient information, relevant diagnostic and treatment information and reflect on health promotion and disease prevention in light of patient factors, such as age, ethnic group, past medical history (PMH), socio-economic status, cultural background, etc.
Note: All Focused Notes must be signed, and each page must be initialed by your preceptor. When you submit your Focused Notes, you should include the complete Focused Note as a Word document and pdf/images of each page that is initialed and signed by your preceptor. You must submit your Focused Notes using SAFE ASSIGN.
Note: Electronic signatures are not accepted. If both files are not received by the due date, faculty will deduct points per the Walden Late Policies.
To prepare:
Reflect on your practicum experience and select a female patient whom you have examined with the support and guidance of your Preceptor.
Think about the details of the patient’s background, medical history, physical exam, labs and diagnostics, diagnosis, and treatment and management plan, and education strategies and follow-up care.
What additional considerations might you think about if your patient was pregnant or just delivered?
Use the “Guidelines for Comprehensive History and Physical SOAP Note” document found in this week’s Learning Resources to guide you as you complete this Assignment.
Assignment:
Write an 8- to 10-page Comprehensive Well-Woman Exam that addresses the following:
Age, race and ethnicity, and partner status of the patient
Current health status, including chief concern or complaint of the patient
Contraception method (if any)
Patient history, including medical history, family medical history, gynecologic history, obstetric history, and personal social history (as appropriate to current problem)
Review of systems
Physical exam
Labs, tests, and other diagnostics
Differential diagnoses
Management plan, including diagnosis, treatment, patient education, and follow-up care
Provide evidence-based guidelines to support treatment plan. Note: Use your Learning Resources and evidence from scholarly sources from your personal search to support your treatment plan of care.
Reflection
Reflect on some additional factors for your patient:
What are the implications if your patient was pregnant or just delivered?
What are implications if you have observed or know of some domestic violence? Would this change your plan of care? If so, how?
Use your Learning Resources and evidence from scholarly sources from your personal search to support your reflection.
Note: Your Comprehensive Well-Woman Exam Assignment must be signed by Day 7 of Week 10.
Jodi clarmont
Patient ID:119531646DOB:1/4/1981Sex:FAccount No.:
Encounter ID:262700526Encounter Date:07/29/2022
Encounter Type: Office Visit
SUBJECTIVE: Chief Complaint: Established care. Physical and well-woman visit History Of Present Illness: The patient is a 41-year-old female who presented for physical and well-woman care. The patient is new in the area, she moves from Michigan state. She has a mood disorder, and is experiencing insomnia, multiple surgery, and digestive issues. The patient was very obese, for which she underwent bariatric surgery. The patient c/o BLE cramping and BUE pain. She needs a psychiatrist in the area. Will need a cardiologist to consult due to a family history of heart disease? Multiple chronic health issues are controlled with medications. Rates bilateral knee pain as 4/10. Medical History: Sphincter of Oddi dysfunction Pancreatitis liver problems Colonoscopy in 2015 Colonoscopy in 1017, repeated in 2020 Sleep apnea Insomnia Depression Panic attacks Mood disorder Surgical History: Pancreatic surgery in 2020 Bariatric surgery in 2018 Hysterectomy in 2012 Cervix removed Breast implant silicone Gynecological History: Hysterectomy in 2012, Cervix removed, Breast implant silicone Family History: Her great grandfather; had colon cancer Father; heart failure Mother; hyperlipidemia and thyroid disease Sibling; Healthy, no health issues Social History:
She drinks I cup of coffee a day a history of 20 years pack smoker-she quit smoking one month ago and started Chantix 1 month ago. The patient denies alcohol intake and the use of illicit drugs. She has used glasses since 2022 and sees an eye doctor. Will need a dentist referral for wisdom teeth removal. She eats 3-5 meals on the go. She sees a psychiatrist in Azle, texas. Smoking Status: Former Smoker Allergies: Trazodone Tramadol Cipro Current Medications: Venlafaxine 150mg ER bid alprazolam 0.25mg daily as needed Hyoscyamine 0.125mg 1 po QID Ondansetron 4mg 1 po as needed Review of System:
Constitutional: Denies weight loss, fever, chills, weakness, or fatigue. Head: Denies headache, lightheadedness, or vertigo Neck: Denies pain, stiffness, or tenderness. Eyes: Denies visual loss, blurred vision, double vision, or yellow sclerae. Ears: Denies hearing loss, tinnitus, pain, vertigo, or use of an assistive hearing device. Nose: Denies sneezing, congestion, runny nose, discharge, obstruction, epistaxis, or sinus issues Mouth: Admit she needs to see the dentist for wisdom teeth removal Throat: Denies sore throat, hoarseness, and dysphagia. Cardiovascular: Denies chest pain, chest pressure, chest discomfort, palpitations, edema, or claudication Respiratory: Denies cough, sputum, SOB, chest congestion, Wheezing, Phlegm, or hemoptysis Gastrointestinal: Admit history Sphincter of Oddi dysfunction, pancreatitis, and liver problems Genitourinary: Denies nocturia, dysuria, incontinence, frequency, urgency, or blood in the urine Musculoskeletal: Admit bilateral knee pain Integumentary(Skin and/or Breast): Denies rash, itching, abnormal lesions or skin problems Neurological: Denies headache, dizziness, syncope, paralysis, ataxia, numbness, or tingling in the extremities. No change in bowel or bladder control. Psychiatric: Admit depression and panic attacks. The patient sees a psychiatrist pcp Endocrine: Admit pancreatitis. Denies Excessive appetite, Excessive thirst, Heat intolerance, Cold intolerance Hematologic/Lymphatic: Denies anemia, bleeding, or bruising. No enlarged nodes. No history of splenectomy Allergic/Immunologic: Denies history of asthma, hives, eczema, itching, nasal congestion, rash, rhinitis, environment
OBJECTIVE: Vital Signs:
Height: 64.00 in Weight: 183.00 lbs BMI: 31.41 Blood Pressure: 114/80 mmHg Temperature: 97.90 F Pulse: 81 beats/min Resp. Rate: 16 Physical Exam:
Constitutional: A 41-year-old well-developed, well-nourished, female who is alert, oriented, and cooperative. She is a good historian and answers questions readily and appropriately. She appears to be in no acute distress. Ears, Nose, Mouth, and Throat: Eyes: PERRLA, EOM’s full, conjunctivae clear, fundi grossly normal, Started using since 2022, ear: EAC’s clear, TM’s normal, Throat: clear, no exudates, Neck: supple, adenopathy, no thyromegaly, no carotid bruits Cardiovascular: Cardiologist consult; family history of heart disease Chest/Breasts: History silicone breast implant Heart: RRR, no murmur, no gallops, or rubs Gastrointestinal (Abdomen): History of Pancreatitis, Genitourinary: no Burning/painful urination, Frequency, Urgency, Night time urination, Blood in the Urine Musculoskeletal: The pat is present with bilateral knee pain Skin: Warm and dry, rashes or abnormal lesions, Extremities: Full ROM without deformities; no clubbing, edema, or cyanosis Neurological/Psychiatric: The patient presented with depression and panic attacks. She sees a psychiatrist
ASSESSMENT: Assessments:
ICD-10 Assessments: Multiple chronic health issues
PLAN: Care Plan: New patient labs work order today. Advise on Mammogram to be done Advise on a healthy diet and exercise to reduce the risk of cardiovascular disease Weight loss to prevent obesity Start gabapentin 600mg po at bedtime Vitamin B12 5000mg Refill needed medications today Cardiologist referral Psychiatrist referral Patient Instructions: Take medication as prescribed
___________________________ Date: _________ [Provider]: Jackie Thomas, APRN Learning Resources
Required Readings (click to expand/reduce)
Fowler, G. C. (2019). Pfenninger and Fowler’s Procedures for Primary Care (4th ed.). Elsevier.
Section 10, “Obstetrics”
Chapter 162, “Dilation and Curettage” (pp. 1093–1099)
Health & Medical Questions Assignment
RUBRIC
QUALITY OF RESPONSE NO RESPONSE POOR / UNSATISFACTORY SATISFACTORY GOOD EXCELLENT Content (worth a maximum of 50% of the total points) Zero points: Student failed to submit the final paper. 20 points out of 50: The essay illustrates poor understanding of the relevant material by failing to address or incorrectly addressing the relevant content; failing to identify or inaccurately explaining/defining key concepts/ideas; ignoring or incorrectly explaining key points/claims and the reasoning behind them; and/or incorrectly or inappropriately using terminology; and elements of the response are lacking. 30 points out of 50: The essay illustrates a rudimentary understanding of the relevant material by mentioning but not full explaining the relevant content; identifying some of the key concepts/ideas though failing to fully or accurately explain many of them; using terminology, though sometimes inaccurately or inappropriately; and/or incorporating some key claims/points but failing to explain the reasoning behind them or doing so inaccurately. Elements of the required response may also be lacking. 40 points out of 50: The essay illustrates solid understanding of the relevant material by correctly addressing most of the relevant content; identifying and explaining most of the key concepts/ideas; using correct terminology; explaining the reasoning behind most of the key points/claims; and/or where necessary or useful, substantiating some points with accurate examples. The answer is complete. 50 points: The essay illustrates exemplary understanding of the relevant material by thoroughly and correctly addressing the relevant content; identifying and explaining all of the key concepts/ideas; using correct terminology explaining the reasoning behind key points/claims and substantiating, as necessary/useful, points with several accurate and illuminating examples. No aspects of the required answer are missing. Use of Sources (worth a maximum of 20% of the total points). Zero points: Student failed to include citations and/or references. Or the student failed to submit a final paper. 5 out 20 points: Sources are seldom cited to support statements and/or format of citations are not recognizable as APA 6th Edition format. There are major errors in the formation of the references and citations. And/or there is a major reliance on highly questionable. The Student fails to provide an adequate synthesis of research collected for the paper. 10 out 20 points: References to scholarly sources are occasionally given; many statements seem unsubstantiated. Frequent errors in APA 6th Edition format, leaving the reader confused about the source of the information. There are significant errors of the formation in the references and citations. And/or there is a significant use of highly questionable sources. 15 out 20 points: Credible Scholarly sources are used effectively support claims and are, for the most part, clear and fairly represented. APA 6th Edition is used with only a few minor errors. There are minor errors in reference and/or citations. And/or there is some use of questionable sources. 20 points: Credible scholarly sources are used to give compelling evidence to support claims and are clearly and fairly represented. APA 6th Edition format is used accurately and consistently. The student uses above the maximum required references in the development of the assignment. Grammar (worth maximum of 20% of total points) Zero points: Student failed to submit the final paper. 5 points out of 20: The paper does not communicate ideas/points clearly due to inappropriate use of terminology and vague language; thoughts and sentences are disjointed or incomprehensible; organization lacking; and/or numerous grammatical, spelling/punctuation errors 10 points out 20: The paper is often unclear and difficult to follow due to some inappropriate terminology and/or vague language; ideas may be fragmented, wandering and/or repetitive; poor organization; and/or some grammatical, spelling, punctuation errors 15 points out of 20: The paper is mostly clear as a result of appropriate use of terminology and minimal vagueness; no tangents and no repetition; fairly good organization; almost perfect grammar, spelling, punctuation, and word usage. 20 points: The paper is clear, concise, and a pleasure to read as a result of appropriate and precise use of terminology; total coherence of thoughts and presentation and logical organization; and the essay is error free. Structure of the Paper (worth 10% of total points) Zero points: Student failed to submit the final paper. 3 points out of 10: Student needs to develop better formatting skills. The paper omits significant structural elements required for and APA 6th edition paper. Formatting of the paper has major flaws. The paper does not conform to APA 6th edition requirements whatsoever. 5 points out of 10: Appearance of final paper demonstrates the student’s limited ability to format the paper. There are significant errors in formatting and/or the total omission of major components of an APA 6th edition paper. They can include the omission of the cover page, abstract, and page numbers. Additionally the page has major formatting issues with spacing or paragraph formation. Font size might not conform to size requirements. The student also significantly writes too large or too short of and paper 7 points out of 10: Research paper presents an above-average use of formatting skills. The paper has slight errors within the paper. This can include small errors or omissions with the cover page, abstract, page number, and headers. There could be also slight formatting issues with the document spacing or the font Additionally the paper might slightly exceed or undershoot the specific number of required written pages for the assignment. 10 points: Student provides a high-caliber, formatted paper. This includes an APA 6th edition cover page, abstract, page number, headers and is double spaced in 12’ Times Roman Font. Additionally, the paper conforms to the specific number of required written pages and neither goes over or under the specified length of the paper.
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