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Assignment NR 602 Week7 SOAP -Lower Abdominal Pain

Assignment: NR 602 Week7 SOAP -Lower Abdominal Pain

K.F. 38yo, F, Latino

S.

CC- Nausea and lower abdominal pain

HPI- The nausea and continuous mild abdominal pain have been present for about 2 weeks, but worsening slightly and now she has developed myalgia and fatigue. She rates the pain 4 on a 1-10 scale. She denies cramping. Reports the pain as “a dull ache”. She has not had a fever, diarrhea, dysuria, rash, headache, blurred vision, and no other household members are ill. She is not taking any current medications. She has been able to eat and drink with some limitations. She has vomited on two occasions, once each week of the abdominal pain. Her LNMP was 10 weeks ago, and she has a history of irregular periods and PCOS, so this pattern is not unusual. She reports she is not currently sexually active and has only been sexually active with her husband whom she is separated from. Her last timing of sexual intercourse was 8 weeks ago, with her estranged husband after a meeting to resolve their separation.

Medications: Tylenol PRN pain, OTC, 1 gram.

Allergies: NKA

PMH: G-4, T-2, P-1, A-1, L-2; cesarean section X 2; no trauma history; 10 year 1PPD smoker, smoking cessation 2 years ago; gestational diabetes with last pregnancy; history of PCOS.

Social History: She continues to live with her parents and is working part time at the children’s school library. She reports her divorce will be final in a matter of a few weeks.

Family history- Maternal and paternal parents are smokers. The mother has been one since age 22 at one pack-per-day until 18 months ago. The father continues to smoke. There were no diseases reported in either parent. Mother has a history with gestational diabetes and preeclampsia.  MGM has a history of hyperlipidemia, Type 2 DM, and Hypertension. They are Latin American in descent, emigrated from Cuba in the 1970s. MGF has a history of hypertension, hyperlipidemia, and an MI with stenting 2 years ago.  The mother has two siblings; one who died in an MVA 5 years ago at the age of 18 a younger brother, and an older sister who is 42 and lives in a large urban city in the Midwest with her family, and she is in good health. Other family members died of old age. She is unaware of paternal familial health history.

NR 602 Week7 SOAP -Lower Abdominal Pain

ROS:

Constitutional- Reports Fatigue.

 

HEENT- Not reported.

 

Skin-  Not reported.

 

Cardiovascular- Not reported.

 

Respiratory- Not reported.

 

Gastrointestinal- Reports nausea and lower abdominal pain “dull ache”. Vomited on 2 occasions.

 

Genitourinary- Reports LNMP was 10 weeks ago, and she has a history of irregular periods and PCOS.

 

Neurological- Not reported.

 

Musculoskeletal- Reports myalgia.

Important information for writing discussion questions and participation

Hi Class,

Please read through the following information on writing a Discussion question response and participation posts.

Contact me if you have any questions.

Important information on Writing a Discussion Question

  • Your response needs to be a minimum of 150 words (not including your list of references)
  • There needs to be at least TWO references with ONE being a peer reviewed professional journal article.
  • Include in-text citations in your response
  • Do not include quotes—instead summarize and paraphrase the information
  • Follow APA-7th edition
  • Points will be deducted if the above is not followed

Participation –replies to your classmates or instructor

  • A minimum of 6 responses per week, on at least 3 days of the week.
  • Each response needs at least ONE reference with citations—best if it is a peer reviewed journal article
  • Each response needs to be at least 75 words in length (does not include your list of references)
  • Responses need to be substantive by bringing information to the discussion or further enhance the discussion. Responses of “I agree” or “great post” does not count for the word count.
  • Follow APA 7th edition
  • Assignment NR 602 Week7 SOAP -Lower Abdominal Pain

    Assignment NR 602 Week7 SOAP -Lower Abdominal Pain

    Points will be deducted if the above is not followed

    Click here to ORDER an A++ paper from our MASTERS and DOCTORATE WRITERS:Assignment: NR 602 Week7 SOAP -Lower Abdominal Pain

Welcome to class

Hello class and welcome to the class and I will be your instructor for this course. This is a -week course and requires a lot of time commitment, organization, and a high level of dedication. Please use the class syllabus to guide you through all the assignments required for the course. I have also attached the classroom policies to this announcement to know your expectations for this course. Please review this document carefully and ask me any questions if you do. You could email me at any time or send me a message via the “message” icon in halo if you need to contact me. I check my email regularly, so you should get a response within 24 hours. If you have not heard from me within 24 hours and need to contact me urgently, please send a follow up text to.

I strongly encourage that you do not wait until the very last minute to complete your assignments. Your assignments in weeks 4 and 5 require early planning as you would need to present a teaching plan and interview a community health provider. I advise you look at the requirements for these assignments at the beginning of the course and plan accordingly. I have posted the YouTube link that explains all the class assignments in detail. It is required that you watch this 32-minute video as the assignments from week 3 through 5 require that you follow the instructions to the letter to succeed. Failure to complete these assignments according to instructions might lead to a zero. After watching the video, please schedule a one-on-one with me to discuss your topic for your project by the second week of class. Use this link to schedule a 15-minute session. Please, call me at the time of your appointment on my number. Please note that I will NOT call you.

Please, be advised I do NOT accept any assignments by email. If you are having technical issues with uploading an assignment, contact the technical department and inform me of the issue. If you have any issues that would prevent you from getting your assignments to me by the deadline, please inform me to request a possible extension. Note that working fulltime or overtime is no excuse for late assignments. There is a 5%-point deduction for every day your assignment is late. This only applies to approved extensions. Late assignments will not be accepted.

If you think you would be needing accommodations due to any reasons, please contact the appropriate department to request accommodations.

Plagiarism is highly prohibited. Please ensure you are citing your sources correctly using APA 7th edition. All assignments including discussion posts should be formatted in APA with the appropriate spacing, font, margin, and indents. Any papers not well formatted would be returned back to you, hence, I advise you review APA formatting style. I have attached a sample paper in APA format and will also post sample discussion responses in subsequent announcements.

Your initial discussion post should be a minimum of 200 words and response posts should be a minimum of 150 words. Be advised that I grade based on quality and not necessarily the number of words you post. A minimum of TWO references should be used for your initial post. For your response post, you do not need references as personal experiences would count as response posts. If you however cite anything from the literature for your response post, it is required that you cite your reference. You should include a minimum of THREE references for papers in this course. Please note that references should be no more than 5 years old except recommended as a resource for the class. Furthermore, for each discussion board question, you need ONE initial substantive response and TWO substantive responses to either your classmates or your instructor for a total of THREE responses. There are TWO discussion questions each week, hence, you need a total minimum of SIX discussion posts for each week. I usually post a discussion question each week. You could also respond to these as it would count towards your required SIX discussion posts for the week.

I understand this is a lot of information to cover in 5 weeks, however, the Bible says in Philippians 4:13 that we can do all things through Christ that strengthens us. Even in times like this, we are encouraged by God’s word that we have that ability in us to succeed with His strength. I pray that each and every one of you receives strength for this course and life generally as we navigate through this pandemic that is shaking our world today. Relax and enjoy the course!

 

Hematological- Not reported.

 

Lymphatics- Not reported.

 

Psychiatric- Not reported.

 

Endocrine- Not reported.

NR 602 Week7 SOAP -Lower Abdominal Pain

O.

Vital Signs: Height: 160 centimeters Weight: 73 kilograms B/P:140/68, T: 99, HR: 92, Resp: 16, reg, non-labored, SpO2: 99%    BMI: 28.5

General: Awake, alert, appropriate; well groomed; tearful at times throughout the exam; skin: warm, dry, intact; HEENT: head normocephalic; Conjunctiva clear, non-icteric, PERRLA, EOM’s intact; tympanic membranes intact, unremarkable; nares patent, unremarkable bilateral; pharynx unremarkable tonsils 2/4 bilateral; neck supple w/o lymphadenopathy.

Cardiopulmonary: Heart RRR w/o murmur; lungs CTA throughout; respirations even and unlabored.

Abdominal: abdomen, soft, with normoactive bowel sounds throughout; tenderness to palpation in the super-pubic area; no masses or organomegally; peripheral pulses reg., equal.

Genitourinary: pelvic exam reveals pink vaginal mucosa with a moderate whitish-clear discharge. Cervical os is mildly injected and easily friable; she is exceedingly tender to palpation, particularly cervical motion tenderness and her uterus is enlarged to about the size of a softball.  Labia majora and minora intact without lesion.

Urinalysis in the office: Cloudy amber yellow urine, Sp. Gr. 1.010, positive WBCs, but no nitrites or leukoesterase; negative for RBCs, glucose, and ketones

Chlamydia and Gonorrhea vaginal cultures sent.

STD Lab Results  

Patient: Kayla Smith

Acc #: 12345

Patient #: 123456KS Birth: 6/18/1987 Collection Date: 11/04/2013 Doctor: NON-STAFF Age: 26 years Received in Lab: 11/04/2013 Home Phone: (301)123-4567 Gender: Female DR SMITH

Test Name Result Flag Reference Interval Lab Chlamydia/GC Amplification

Chlamydia trachomatis, NAA Positive Abnormal

Neisseria gonorrheae, NAA Negative

Urine Pregnancy Test—Positive

A.

Primary Diagnosis:

Pregnant state, incidental (Z33.1) – Urine pregnancy test is positive. (Fenstermacher & Hudson, 2016) Kayla’s urine pregnancy test was positive.

Secondary Diagnosis:

Chlamydia (A74.9) – 
Chlamydia trachomatis is the leading cause of infertility, ectopic pregnancy and pelvic inflammatory disease. Symptoms may be asymptomatic with mild dyspareunia, mucopurulent cervicitis or vaginal discharge with spotting after sex and pelvic pain. Exam reveals cervical motion tenderness with purulent discharge from cervix; the cervix appears friable with erosions and irritation (Fenstermacher & Hudson, 2016). Kayla has moderate whitish-clear discharge, cervical os is mildly injected and easily friable; she is exceedingly tender to palpation, particularly cervical motion tenderness. Along with a positive Chlamydia test.

Pelvic inflammatory disease, unspecified (N73.9) – This is a vaginal infection that causes abdominal pain, uterine tenderness, abnormal cervical or vaginal mucopurulent discharge, and cervical motion tenderness (Schuiling & Likis, 2013). Kayla is having lower abdominal pain with injected and easily friable cervix and cervical motion tenderness. Chlamydia and Gonorrhea vaginal cultures sent.

Cervical dysplasia (N87.0) – Kayla has ASCUS which stands for atypical cell of undetermined significance, she has abnormal cervical cells. With this result the provider should next check for the presents of the virus human papillomavirus (HPV) (Fontaine, Saslow, & King, 2012). Kayla still had not gone to the OB/GYN about her abnormal cervical cells.

NR 602 Week7 SOAP -Lower Abdominal Pain

Differential Diagnosis:

P.

Diagnostics:

,,,

Education

ORDER NOW FOR A CUSTOM-WRITTEN, PLAGIARISM-FREE PAPER WITH ALL INSTRUCTIONS FOLLOWED

References

Centers for Disease Control and Prevention (CDC). (2015, June 4). Gonococcal infections. Retireved from http://www.cdc.gov/std/tg2015/gonorrhea.htm.

Epocrates. (2015). Zithromycin. Retrieved from https://online.epocrates.com/rxmain.

Epocrates. (2015). Ceftriaxone. Retrieved from https://online.epocrates.com/rxmain.

Epocrates. (2015). Prenatal vitamin. Retrieved from https://online.epocrates.com/rxmain.

Fenstermacher, K. & Hundson, B. T. (2016). Practice Guidelines for Family Nurse Practitioners (4th ed.). St. Louis, MO: Elsevier.

Fontaine, P. L., Saslow, D., & King, V. J. (2012, September 15). ACS/ASCCP/ASCP guidelines for the early detection of cervical cancer. American Family Physician, 86(6), 501-508.

Jucktee, G. & Hartman-Adams, H. (2010, November 15). Human papillomavirus: clinical manifestations and prevention. American Family Physician, 82(10), 1209-1214.

Mayor, M., Roett, M. A., & Uduhiri, K. A. (2012, November 15). Diagnosis and management of gonococcal infections. American Family Physicians, 86(10), 931-938.

Mishori, R., McClaskey, E. L., & Winklerprins, V. J. (2012, December 15). Chlamydia trachomatis infections: screening, diagnosis, and management. American Family Physician, 86(12), 1127-1132.

Moss, D. A., Snyder, M. J., & Lin, L. (2015, April 15). Options for women with unintended pregnancy. American Family Physician, 91(8), 544-549.

Schuiling, K. & Likis, F. (2013). Women’s gynecologic health (Second ed.). Burlington, MA: Jones & Bartlett Learning, LLC.

Zolotor, A. J. & Carlough, M. C. (2014, Feburary 1). Update on prenatal care. American Family Physician, 89(3), 199-208.

Important information for writing discussion questions and participation

Hi Class,

Please read through the following information on writing a Discussion question response and participation posts.

Contact me if you have any questions.

Important information on Writing a Discussion Question

  • Your response needs to be a minimum of 150 words (not including your list of references)
  • There needs to be at least TWO references with ONE being a peer reviewed professional journal article.
  • Include in-text citations in your response
  • Do not include quotes—instead summarize and paraphrase the information
  • Follow APA-7th edition
  • Points will be deducted if the above is not followed

Participation –replies to your classmates or instructor

  • A minimum of 6 responses per week, on at least 3 days of the week.
  • Each response needs at least ONE reference with citations—best if it is a peer reviewed journal article
  • Each response needs to be at least 75 words in length (does not include your list of references)
  • Responses need to be substantive by bringing information to the discussion or further enhance the discussion. Responses of “I agree” or “great post” does not count for the word count.
  • Follow APA 7th edition
  • Points will be deducted if the above is not followed

Welcome to class

Hello class and welcome to the class and I will be your instructor for this course. This is a -week course and requires a lot of time commitment, organization, and a high level of dedication. Please use the class syllabus to guide you through all the assignments required for the course. I have also attached the classroom policies to this announcement to know your expectations for this course. Please review this document carefully and ask me any questions if you do. You could email me at any time or send me a message via the “message” icon in halo if you need to contact me. I check my email regularly, so you should get a response within 24 hours. If you have not heard from me within 24 hours and need to contact me urgently, please send a follow up text to.

I strongly encourage that you do not wait until the very last minute to complete your assignments. Your assignments in weeks 4 and 5 require early planning as you would need to present a teaching plan and interview a community health provider. I advise you look at the requirements for these assignments at the beginning of the course and plan accordingly. I have posted the YouTube link that explains all the class assignments in detail. It is required that you watch this 32-minute video as the assignments from week 3 through 5 require that you follow the instructions to the letter to succeed. Failure to complete these assignments according to instructions might lead to a zero. After watching the video, please schedule a one-on-one with me to discuss your topic for your project by the second week of class. Use this link to schedule a 15-minute session. Please, call me at the time of your appointment on my number. Please note that I will NOT call you.

Please, be advised I do NOT accept any assignments by email. If you are having technical issues with uploading an assignment, contact the technical department and inform me of the issue. If you have any issues that would prevent you from getting your assignments to me by the deadline, please inform me to request a possible extension. Note that working fulltime or overtime is no excuse for late assignments. There is a 5%-point deduction for every day your assignment is late. This only applies to approved extensions. Late assignments will not be accepted.

If you think you would be needing accommodations due to any reasons, please contact the appropriate department to request accommodations.

Plagiarism is highly prohibited. Please ensure you are citing your sources correctly using APA 7th edition. All assignments including discussion posts should be formatted in APA with the appropriate spacing, font, margin, and indents. Any papers not well formatted would be returned back to you, hence, I advise you review APA formatting style. I have attached a sample paper in APA format and will also post sample discussion responses in subsequent announcements.

Your initial discussion post should be a minimum of 200 words and response posts should be a minimum of 150 words. Be advised that I grade based on quality and not necessarily the number of words you post. A minimum of TWO references should be used for your initial post. For your response post, you do not need references as personal experiences would count as response posts. If you however cite anything from the literature for your response post, it is required that you cite your reference. You should include a minimum of THREE references for papers in this course. Please note that references should be no more than 5 years old except recommended as a resource for the class. Furthermore, for each discussion board question, you need ONE initial substantive response and TWO substantive responses to either your classmates or your instructor for a total of THREE responses. There are TWO discussion questions each week, hence, you need a total minimum of SIX discussion posts for each week. I usually post a discussion question each week. You could also respond to these as it would count towards your required SIX discussion posts for the week.

I understand this is a lot of information to cover in 5 weeks, however, the Bible says in Philippians 4:13 that we can do all things through Christ that strengthens us. Even in times like this, we are encouraged by God’s word that we have that ability in us to succeed with His strength. I pray that each and every one of you receives strength for this course and life generally as we navigate through this pandemic that is shaking our world today. Relax and enjoy the course!

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