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Assignment NR511 Elog Soap Wk4

Assignment: NR511 Elog Soap Wk4

SOAP Note 4

Patient Information:

P.B. 51, Male, Caucasian, Commercial Insurance

S: Subjective:

Chief Complaint (CC): 51 year old male presents today with a complaint of “tearing and sensitivity to light” in right eye.  Patient also c/o redness to right eye.

HPI:

Onset: 2 days

Location: Right Eye

Duration: 2 day

Characteristics: Tearing, redness and sensitive to light. 

Aggravating Factors: Light

Relieving Factors: None reported

Treatment: None reported

Current MedicationsNo prescribed medications.  No OTC medications or herbal supplements.

Allergies: NKA

PMHx:

No chronic illness or injuries. No surgical history. Immunizations are up-to-date. Tetanus Booster unknown.

NR511 Elog Soap Wk4

Soc Hx:

Master graduate and is currently employed at the Space Center as an engineer.  

Patient is married with four children. 

Patient has never smoked cigarettes, or any recreational substances. 

Patient states he enjoys traveling. 

Fam Hx:

Mother (85 years old) and father (86years old) currently live nearby.  Mother hx of hypertension and hyperlipidemia. Father with hx of hyperlipidemia, hypertension.  One brother (48 years old) with no medical problems.

All children are alive with no medical conditions to his knowledge.

Review of Symptoms (ROS):

CONSTITUTIONAL:  No weight loss, fever, chills, weakness or fatigue.

Assignment NR511 Elog Soap Wk4

Assignment NR511 Elog Soap Wk4

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HEENT:  Head – no headache, dizziness, or syncope. Eyes:  + (clear watery discharge with redness in right eye).  Ears – no hearing loss, no ear discharge, or swelling.  Nose – no sneezing, congestion, or runny nose.

CARDIOVASCULAR:  No chest pain, chest pressure or chest discomfort. No palpitations or edema.

RESPIRATORY:  No shortness of breath, cough or sputum.

ALLERGIES:  NKDA

O: Objective Data

Temperature: 98.5 oral, Pulse 78, R 16, BP 134/74, O2 100%, Height 5’9”, Weight 169lbs. BMI: 25.0 (Normal).

Physical exam:

GENERAL APPEARANCE: Well groomed, well nourished, alert and cooperative, and appears to be in no apparent distress. Appropriately dressed male.

HEENT: Head- Normocephalic, atraumatic, symmetric, non-tender, normal inspection. Eyes: Left eye: no erythema or exudate noted. Sclera is clear.  Right eye: thin clear watery discharge.  Conjunctiva: Red, PERRLA, EOMs intact.  Corneal light reflex symmetrical bilaterally.  Fundi: red reflex present bilaterally, Discs flat with sharp margins. Vessels present in all quadrants without crossing defects. Retinal background has even color, no hemorrhages noted. Macula has even color.   Visual acuity and extraocular eye movements intact. No nystagmus noted. Ears: Bilateral canals patent without erythema, edema, or exudate. Bilateral tympanic membranes intact, pearly gray with sharp cone of light. Nose: Bilateral nares intact.  No deviation or perforated septum.  No transverse nasal crease noted. Throat: uvula midline. No erythema, swelling, exudate, or lesion noted.  Teeth and gingiva in good general condition.

NECK/LYMPHATICS:  Supple, non-tender.  Trachea midline, no swelling. No cervical, submental, post-auricular, or supraclavicular lymphadenopathy noted. No thyroid nodule or thyromegaly. No palpable masses.

RESPIRATORY/CHEST: No resp. distress. No use of accessory muscles.  Lungs resonant upon percussion.  Breath sounds normal to auscultation, no adventitious sounds noted.  Thorax symmetric, with symmetric expansion.

CVS: No murmurs, rubs, or gallops.  S1 and S2 normal.  Rhythm is regular.  There is no peripheral edema, cyanosis or pallor.  Extremities are warm and well perfused.  Capillary refill is less than 3 seconds.  No carotid bruits.

A: Assessment:

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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