NURS 6541 Week 7 SOAP Note Assignment

NURS 6541 Week 7 SOAP Note Assignment

NURS 6541 Week 7 SOAP Note Assignment

HPI: 7-year old female fully immunized with complaints of bilateral ear pain for the past two days. The patient had rhinorrhea, nasal congestion, and cough for one week that seemed to have resolved 3 days ago. The patient was afebrile during this illness. Yesterday and today child was febrile as high as 102.5. The mother states that she has been alternating Tylenol and Motrin for pain control. The child has been more tired than usual all day today. Patient did not sleep well last night was up complaining of ear pain in both ears. No change in eating or elimination patterns. No sick contacts. NURS 6541 Week 7 SOAP Note Assignment



NURS 6541 Week 8 Journal – Hematologic and Metabolic Disorders

Ematologic and Metabolic Disorders

In week 5 of clinical I had the opportunity to examine a patient with congenital adrenal hypothyroidism. This patient was a male and was 11 years old.

Reflect on a patient who presented with a hematologic or metabolic disorder during your Practicum experience. Describe your experience in assessing and managing the patient and his or her family. Include details of your aha moment in identifying the patients disorder. Then explain how the experience connected your classroom studies to the real-world clinical setting. If you did not have an opportunity to evaluate a patient with this background during the last 8 weeks you may select a related case study from a reputable source or reflect on previous clinical experiences.

NURS 6541 Week 9 Journal Gastrointestinal Disorders

Gastrointestinal Disorders

During this practicum, I had the opportunity to see a 7-year-old male patient previously diagnosed with encopresis. Now, the child was in the office for a 6 month…

Many genitourinary (GU) disorders such as kidney disease begin developing during childhood and adolescence (Johns Hopkins Children’s Center, 2010). This early onset of disease makes it essential for you, as the advanced practice nurse caring for pediatric patients, to identify potential signs and symptoms. Although some pediatric GU disorders require long-term treatment and management, other disorders such as bedwetting or urinary tract infections are more common and frequently require only minor interventions. In your role with pediatric patients, you must evaluate symptoms and determine whether to treat patients or refer them for specialized care. For this Discussion, consider potential diagnoses, treatment, and/or referral options for the patients in the following three case studies.

Discussion board posting assignments are assigned alphabetically by FIRST NAME to ensure all cases are covered and discussed.

Case Study 1: A-F
Case Study 2: G-M
Case Study 3: N-T
Case Study 4: U-Z

Case Study 1

HPI: This is a 3 year old girl with a 2-day history of complaints of dysuria with frequent episodes of enuresis despite potty training about 7 months ago. She is afebrile and denies vomiting.

PMH: Last UTI, 6 months ago.
PE: Dipstick voided urine analysis reveals: specific gravity 1.015, Protein 1+ non-hemolyzed blood, 1+ nitrites, 1+ leukocytes, and glucose-negative.

Case Study 2

Jacob is a 1.5 week old brought in by his distressed mother. While changing his diaper last night, she noted that his penis was edematous and erythematous. He has been crying and fussy. Per mom, no other complaints. He’s been breastfeeding every 1-2 hours without any issues.

PE: Stable VS and growth patterns. Essentially a normal examination with the exception of a slightly erythematous and edematous glans penis with retracted prepuce.

Case Study 3

HPI: Mark is a 15-year-old with complaint of acute left scrotal pain with nausea. The pain began approximately 6 hours ago after a wrestling match. He describes the pain as a dull ache and has gradually worsened to where he can no longer stand without doubling over. He is afebrile and in marked pain.

PE: Physical exam is negative except for elevation of the left testicle, diffuse scrotal edema, and the presence of a blue dot sign.

Case Study 4

HPI: Maya is a 5-year-old who presents for a well-child visit. She is a healthy child with no complaints.

PE: VS stable; Height and weight within the 60th percentile. Head to toe examination is normal.
Diagnostics: Routine urinalysis indicates 2+ proteinuria; specific gravity 1.020; negative for glucose, blood, leukocytes, and nitrites. 60th percentile for height and weight.


To prepare:

Review “Genitourinary Disorders” in the Burns et al. text.
Review and select one of the three provided case studies. Analyze the patient information.
Consider a differential diagnosis for the patient in the case study you selected. Think about the most likely diagnosis for the patient.
Think about a treatment and management plan for the patient. Be sure to consider appropriate dosages for any recommended pharmacologic and/or non-pharmacologic treatments.
Consider strategies for educating patients and families on the treatment and management of the genitourinary disorder.

By Day 3

Post an analysis of your assigned case by responding to the following:

What additional questions will you ask?
Has the case addressed the LOCATES mnemonic? If not, what else do you need to ask? What additional history will you need? (Think FMH, allergies, meds and so forth, that might be pertinent in arriving to your differential diagnoses).
What additional examinations or diagnostic tests, if any will you conduct?
What are your differential diagnoses? What historical and physical exam features support your rationales? Provide at least 3 differentials.
What is your most likely diagnosis and why?
How will you treat this child?
Provide medication treatment and symptomatic care.
Provide correct medication dosage. Use the knowledge you learned from this week’s and previous weeks’ readings as well as what you have learned from pharmacology to help you with this area.
Patient Education, Health Promotion & Anticipatory guidance:
Explain strategies for educating parents on their child’s disorder and reducing any concerns/fears presented in the case study.
Include any socio-cultural barriers that might impact the treatment and management plans.
Health Promotion:
What immunizations should this child have had?
Based on the child’s age, when is the next well visit?
At the next well visit, what are the next set of immunizations?
What additional anticipatory guidance should be provided today?

Read a selection of your colleagues’ responses.

By Day 6

Respond to at least two of your colleagues on two different days in both of the ways listed below. Respond to colleagues who selected different case studies than you did.

Describe how culture might impact the diagnosis, management, and follow-up care of patients with the genitourinary disorders your colleagues discussed.
Based on your personal and/or professional experiences, expand on your colleagues’ postings by providing additional insights or different perspectives.

Note: For this Discussion, you are required to complete your initial post before you will be able to view and respond to your colleagues’ postings. Begin by clicking on the “Post to Discussion Question” link and then select “Create Thread” to complete your initial post. Remember, once you click on Submit, you cannot delete or edit your own posts, and you cannot post anonymously. Please check your post carefully before clicking on Submit!

NURS 6541 Week 10 SOAP (Walden)




ASSESSMENT: (Primary diagnosis)