Soap Note

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https://www.slideshare.net/slideshow/case-study-dev-cordoba-2021-walden-university-llc-1/253073073#1

 Review the video, Case Study: Dev Cordoba. You will use this case as the basis of this Assignment.  

 

Develop a Focused SOAP Note, including your differential diagnosis and critical-thinking process to formulate a primary diagnosis. Incorporate the following into your responses in the template:

  • Subjective: What details did the patient provide regarding their chief complaint and symptomology to derive your differential diagnosis? What is the duration and severity of their symptoms? How are their symptoms impacting their functioning in life?
  • Objective: What observations did you make during the psychiatric assessment?  
  • Assessment: Discuss the patient’s mental status examination results. What were your differential diagnoses? Provide a minimum of three possible diagnoses with supporting evidence, listed in order from highest priority to lowest priority. Compare the DSM-5-TR diagnostic criteria for each differential diagnosis and explain what DSM-5-TR criteria rules out the differential diagnosis to find an accurate diagnosis. Explain the critical-thinking process that led you to the primary diagnosis you selected. Include pertinent positives and pertinent negatives for the specific patient case.
  • Plan: What is your plan for psychotherapy? What is your plan for treatment and management, including alternative therapies? Include pharmacologic and nonpharmacologic treatments, alternative therapies, and follow-up parameters, as well as a rationale for this treatment and management plan. Also incorporate one health promotion activity and one patient education strategy.
  • Reflection notes: What would you do differently with this patient if you could conduct the session again? Discuss what your next intervention would be if you could follow up with this patient. Also include in your reflection a discussion related to legal/ethical considerations (demonstrate critical thinking beyond confidentiality and consent for treatment!), health promotion, and disease prevention, taking into consideration patient factors (such as age, ethnic group, etc.), PMH, and other risk factors (e.g., socioeconomic, cultural background, etc.).
  • Provide at least three evidence-based, peer-reviewed journal articles or evidenced-based guidelines that relate to this case to support your diagnostics and differential diagnoses. Be sure they are current (no more than 5 years old).

References:

 

  • Boland, R. Verdiun, M. L. & Ruiz, P. (2022). Kaplan & Sadock’s synopsis of psychiatry (12th ed.). Wolters Kluwer. 
    • Chapter 2, “Neurodevelopmental Disorders and Other Childhood Disorders”
      • Section 2.8, “Trauma- and Stressor-Related Disorders in Children” (pp. 167-173)
      • Section 2.13, “Anxiety Disorders of Infancy, Childhood, and Adolescence: Separation Anxiety Disorder, Generalized Anxiety Disorder, and Social Anxiety Disorder (Social Phobia)” (pp. 194-200”)
      • Section 2.14, “Selective Mutism” (pp.  201-202)
      • Section 2.15, “Obsessive-Compulsive Disorder in Childhood and Adolescence” (pp. 203-206)
    • Chapter 8, “Anxiety Disorders”
    • Chapter 9, “Obsessive-Compulsive and Related Disorders”
    • Chapter 10, “Trauma- and Stressor-Related Disorders
  • Thapar, A., Pine, D. S., Leckman, J. F., Scott, S., Snowling, M. J., & Taylor, E. A. (Eds.). (2015). Rutter’s child and adolescent psychiatry (6th ed.). Wiley Blackwell.
    • Chapter 26, “Psychosocial Adversity”
    • Chapter 27, “Resilience: Concepts, Findings, and Clinical Implications”
    • Chapter 29, “Child Maltreatment”
    • Chapter 30, Child Sexual Abuse”
    • Chapter 58, “Disorders of Attachment and Social engagement Related to Deprivation”
    • Chapter 59, “Post Traumatic Stress Disorder”

Evidence-Based Project, Part 1: Identifying Research Methodologies

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After reading each of the four peer-reviewed articles you selected, use the Matrix Worksheet template to analyze the methodologies applied in each of the four peer-reviewed articles. Your analysis should include the following:

  • The full citation of each peer-reviewed article in APA format.
  • A brief (1-paragraph) statement explaining why you chose this peer-reviewed article and/or how it relates to your clinical issue of interest, including a brief explanation of the ethics of research related to your clinical issue of interest.
  • A brief (1-2 paragraph) description of the aims of the research of each peer-reviewed article.
  • A brief (1-2 paragraph) description of the research methodology used. Be sure to identify if the methodology used was qualitative, quantitative, or a mixed-methods approach. Be specific.
  • A brief (1- to 2-paragraph) description of the strengths of each of the research methodologies used, including reliability and validity of how the methodology was applied in each of the peer-reviewed articles you selected.

XD04work

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XD04

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WK 3 REP EPID

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week 2 q

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 Question 1

Identify the full name of guideline you have identified. This will be your choice from the three options above: A pending bill, a current policy, or the development of a new bill. Include in your response a direct link to the bill or policy you are referring to or a copy of the health policy. If you are recommending a new bill, please include a one-page draft of your recommendation.

 Question 2

Identify the level at which you will advocate for your bill or policy.

  • If its legislation, please let us know whether it falls into the scope of the House or Senate and if it’s at the Federal or State level
  • If you chose a healthcare policy, please identify the scope as the community, a facility, an insurance agency etc.

 

Question 3

Provide a detailed explanation with a minimum of two reasons why this healthcare policy or bill is important. Scholarly support and citations are required.

 Question 5Using this link with your current address, please identify your US legislators. https://www.congress.gov/members/find-your-memberLinks to an external site..  Identify the leader or change agent by name as well as their role from the level you noted in question 2. Tell us who is appropriate to advocate for this policy change or adoption. Example: Ted Cruz, US Senate, Texas; Adam Anderson, State House of Representatives, Florida; Dr. Olivia Smith, Director, Office of Health Equity.  After identifying the appropriate leader or change agent, in 2-4 sentences, describe why this individual is the most appropriate to advocate for this policy change or adoption. 

 

Question 6

What is the leader or representative’s mailing address AND email address? 

 

Question 7

State the member of your community who you can elicit feedback from regarding your policy advocacy efforts. Please tell us their first name and their role in your community as well as an email or phone number to contact them. This individual can be a neighbor, coworker, family member etc.. who lives in your community and interacts with the healthcare system in any way (patient family member, healthcare provider). Upload the completed Stakeholder Validation Tool here.

NUR 691 B week 4

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work study

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NUR 502 Module 3 Discussion

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Pulmonary Function:
D.R. is a 27-year-old man, who presents to the nurse practitioner at the Family Care Clinic complaining of increasing SOB, wheezing, fatigue, cough, stuffy nose, watery eyes, and postnasal drainage—all of which began four days ago. Three days ago, he began monitoring his peak flow rates several times a day. His peak flow rates have ranged from 65-70% of his regular baseline with nighttime symptoms for 3 nights on the last week and often have been at the lower limit of that range in the morning. Three days ago, he also began to self-treat with frequent albuterol nebulizer therapy. He reports that usually his albuterol inhaler provides him with relief from his asthma symptoms, but this is no longer enough treatment for this asthmatic episode.

Case Study Questions

  1. According to the case study information, how would you classify the severity of D.R. asthma attack?
  2. Name the most common triggers for asthma in any given patients and specify in your answer which ones you consider applied to D.R. on the case study.
  3. Based on your knowledge and your research, please explain the factors that might be the etiology of D.R. being an asthmatic patient.

Fluid, Electrolyte and Acid-Base Homeostasis:
Ms. Brown is a 70-year-old woman with type 2 diabetes mellitus who has been too ill to get out of bed for 2 days. She has had a severe cough and has been unable to eat or drink during this time. On admission, her laboratory values show the following:

  • Serum glucose 412 mg/dL
  • Serum sodium (Na+) 156 mEq/L
  • Serum potassium (K+) 5.6 mEq/L
  • Serum chloride (Cl–) 115 mEq/L
  • Arterial blood gases (ABGs): pH 7.30; PaCO2 32 mmHg; PaO2 70 mmHg; HCO3– 20 mEq/L

Case Study Questions

  1. Based on Ms. Brown admission’s laboratory values, could you determine what type of water and electrolyte imbalance does she has?
  2. Describe the signs and symptoms to the different types of water imbalance and described clinical manifestation she might exhibit with the potassium level she has.
  3. In the specific case presented which would be the most appropriate treatment for Ms. Brown and why?
  4. What the ABGs from Ms. Brown indicate regarding her acid-base imbalance?
  5. Based on your readings and your research define and describe Anion Gaps and its clinical significance.

Submission Instructions:

  • You must complete both case studies
  • Your initial post should be at least 500 words per case study, formatted and cited in current APA style with support from at least 2 academic sources.