Soap Note 2 Crohn’s disease

this is a template example. Have to be with the same format but with a new patient with Crohn’s disease
(Student Name)
Miami Regional University
Date of Encounter:
Preceptor/Clinical Site:
Clinical Instructor: Dr. David Trabanco DNP, APRN, AGNP-C, FNP-C
Soap Note # Main Diagnosis ( Exp: Soap Note #3 DX: Hypertension)
PATIENT INFORMATION
Name: Mr. DT
Age: 68-year-old
Gender at Birth: Male
Gender Identity: Male
Source: Patient
Allergies: PCN, Iodine
Current Medications:
Atorvastatin tab 20 mg, 1-tab PO at bedtime
ASA 81mg po daily
Multi-Vitamin Centrum Silver
PMH: Hypercholesterolemia
Immunizations: Influenza last 2018-year, tetanus, and hepatitis A and B 4 years ago.
Preventive Care: Coloscopy 5 years ago (Negative)
Surgical History: Appendectomy 47 years ago.
Family History: Father- died 81 does not report information
Mother-alive, 88 years old, Diabetes Mellitus, HTN
Daughter-alive, 34 years old, healthy
Social History: No smoking history or illicit drug use, occasional alcoholic beverage consumption on social celebrations. Retired, widow, he lives alone.
Sexual Orientation: Straight
Nutrition History: Diets off and on, Does not each seafood
Subjective Data:
Chief Complaint: headaches that started two weeks ago
Symptom analysis/HPI:
The patient is 65 years old male who complaining of episodes of headaches and on 3 different occasions blood pressure was measured, which was high (159/100, 158/98 and 160/100 respectively). Patient noticed the problem started two weeks ago and sometimes it is accompanied by dizziness. He states that he has been under stress in his workplace for the last month. Patient denies chest pain, palpitation, shortness of breath, nausea or vomiting.
Review of Systems (ROS)
CONSTITUTIONAL: Denies fever or chills. Denies weakness or weight loss. NEUROLOGIC: Headache and dizziness as describe above. Denies changes in LOC. Denies history of tremors or seizures.
HEENT: HEAD: Denies any head injury, or change in LOC. Eyes: Denies any changes in vision, diplopia or blurred vision. Ear: Denies pain in the ears. Denies loss of hearing or drainage. Nose: Denies nasal drainage, congestion. THROAT: Denies throat or neck pain, hoarseness, difficulty swallowing.
RESPIRATORY: Patient denies shortness of breath, cough or hemoptysis.
CARDIOVASCULAR: No chest pain, tachycardia. No orthopnea or paroxysmal nocturnal
dyspnea.
GASTROINTESTINAL: Denies abdominal pain or discomfort. Denies flatulence, nausea, vomiting or
diarrhea.
GENITOURINARY: Denies hematuria, dysuria or change in urinary frequency. Denies difficulty starting/stopping stream of urine or incontinence.
MUSCULOSKELETAL: Denies falls or pain. Denies hearing a clicking or snapping sound.
SKIN: No change of coloration such as cyanosis or jaundice, no rashes or pruritus.
Objective Data:
VITAL SIGNS: Temperature: 98.5 F, Pulse: 87, BP: 159/92 mmhg, RR 20, PO2-98% on room air, Ht- 64, Wt 200 lb, BMI 25. Report pain 2/10.
GENERAL APPREARANCE: The patient is alert and oriented x 3. No acute distress noted. NEUROLOGIC: Alert, CNII-XII grossly intact, oriented to person, place, and time. Sensation intact to bilateral upper and lower extremities. Bilateral UE/LE strength 5/5.
HEENT: Head: Normocephalic, atraumatic, symmetric, non-tender. Maxillary sinuses no tenderness. Eyes: No conjunctival injection, no icterus, 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. Maxillary sinuses no tenderness. Nasal mucosa moist without bleeding. Oral mucosa moist without lesions,. Lids non-remarkable and appropriate for race.
Neck: supple without cervical lymphadenopathy, no jugular vein distention, no thyroid swelling or masses.
CARDIOVASCULAR: S1S2, regular rate and rhythm, no murmur or gallop noted. Capillary refill < 2 sec. RESPIRATORY: No dyspnea or use of accessory muscles observed. No egophony, whispered pectoriloquy or tactile fremitus on palpation. Breath sounds presents and clear bilaterally on auscultation. GASTROINTESTINAL: No mass or hernia observed. Upon auscultation, bowel sounds present in all four quadrants, no bruits over renal and aorta arteries. Abdomen soft non-tender, no guarding, no rebound no distention or organomegaly noted on palpation MUSKULOSKELETAL: No pain to palpation. Active and passive ROM within normal limits, no stiffness. INTEGUMENTARY: intact, no lesions or rashes, no cyanosis or jaundice. ASSESSMENT: Main Diagnosis Essential (Primary) Hypertension (ICD10 I10): Given the symptoms and high blood pressure (156/92 mmhg), classified as stage 2. Once the organic cause of hypertension has been ruled out, such as renal, adrenal or thyroid, this diagnosis is confirmed (Codina Leik, 2015). Diagnosis is based on the clinical evaluation through history, physical examination, and routine laboratory tests to assess risk factors, reveal identifiable causes and detect target-organ damage, including evidence of cardiovascular disease (Domino et al,. 2017). Differential diagnosis: Renal artery stenosis (ICD10 I70.1) Chronic kidney disease (ICD10 I12.9) Hyperthyroidism (ICD10 E05.90) PLAN: Labs and Diagnostic Test to be ordered: CMP Complete blood count (CBC) Lipid profile Thyroid-stimulating hormone (TSH) Urinalysis with Micro Electrocardiogram (EKG 12 lead) Pharmacological treatment: Hydrochlorothiazide tab 25 mg, Initial dose: 25 mg orally once daily. Lisinopril 10mg PO Daily Non-Pharmacologic treatment: Weight loss Healthy diet (DASH dietary pattern): Diet rich in fruits, vegetables, whole grains, and low-fat dairy products with reduced content of saturated and trans l fat Reduced intake of dietary sodium: <1,500 mg/d is optimal goal but at least 1,000 mg/d reduction in most adults Enhanced intake of dietary potassium Regular physical activity (Aerobic): 90150 min/wk Tobacco cessation Measures to release stress and effective coping mechanisms. Education Provide with nutrition/dietary information. Daily blood pressure monitoring log at home twice a day for 7 days, keep a record, bring the record on the next visit with her PCP Instruction about medication intake compliance. Education of possible complications such as stroke, heart attack, and other problems. Patient was educated on course of hypertension, as well as warning signs and symptoms, which could indicate the need to attend the E.R/U.C. Answered all pt. questions/concerns. Pt verbalizes understanding to all Follow-ups/Referrals Follow up appointment 1 weeks for managing blood pressure and to evaluate current hypotensive therapy. No referrals needed at this time. References Codina Leik, M. T. (2014). Family Nurse Practitioner Certification Intensive Review (2nd ed.). ISBN 978-0-8261-3424-0 Domino, F., Baldor, R., Golding, J., Stephens, M. (2017). The 5-Minute Clinical Consult 2017 (25th ed.). Print (The 5-Minute Consult Series).

1. What was meant by Black Land and Red Land in ancient Egypt? Why?

1. What was meant by Black Land and Red Land in ancient Egypt? Why?

2. Define the following:

lily and papyrus knotted —

ankh —

vizier —

3. When ancient Egyptian art was originally set up, as in sculptures, it made sense for them to look __________________. Why?

4. Spaces ________________ [are or are not] cut away between arms and the body. Why?

5. What is composite assembly regarding the painting of figures of high social status in ancient Egypt as on walls, etc.?

6. How does scale reflect the hierarchical ordering of society?

7. For what purposes are the hieroglyphics included?
Can they be reversed?

10. Their paper, or writing surface, for documents and texts was called

_________________.

Reading List & Ratinale

Text Book used:The Norton Anthology World Literature Vol 1Shorter 4 TH Edition.
The Reading List & Rationale assignment is very straightforward. I am looking for exactly what the instructions list. Do not make it more complicated than it is. Follow the directions line by line:
Part 1. Compile a reading list from the textbook used in this course for your ideal LIT 2110 World Literature I course. Your list should include at least 8 selections, and should best represent your understanding of how literature is an artifact of its culture. Include titles and authors. Include specific sections, chapters, or pages, if applicable. You may, OF COURSE, include literature we’ve read together. There’s nothing here prohibiting that. The assignment does not specify a minimum or maximum number of works of literature so there is no maximum or minimum. The right number is however many texts you feel a student could reasonably read in an ordinary 16 week semester and how many texts a student should read to best accomplish the student learning outcomes of World Literature. THIS ASSIGNMENT IS A TEST OF YOUR ANALYTICAL AND LOGIC SKILLS. YOU HAVE TO FIGURE OUT THESE SPECIFICS AND THEN JUSTIFY YOUR CHOICES.
Part II Below youre the list you compiled, Write a RATIONALE of 750-1000 words for your reading list that identifies your theme and how the readings support that theme. Consider the rationale on the course syllabus, the course introduction video, and the monomyth video. Your audience is not me, but students new to World Literature I, like you were 4 months ago. Justify your choices–all of them. Explain the theme you’ve chosen. The theme is the primary understanding about world literature, world cultures, and/or any other aspect of humanity that you think students should come away with. Our theme is the quest–this, to me, is why we create art and experience art. For you, it might be that or something different. Make a choice and justify it. Explain how many works you’ve chosen to demonstrate that theme and why. Explain why you’ve chosen the works you’ve chosen. How do each of these works demonstrate the theme? If you need a model, follow the links in the assignment instructions. Our syllabus and the videos introducing the course ARE models.
3. Upload a polished presentation of your reading list and rationale/course introduction in a SINGLE Word file. Include an MLA style header. Polished means professional, no errors, ready to share with the world.
If you have questions, of course reach out, but do some due diligence first. Look up words in a dictionary. Explore the resources I’ve offered you. SLOW down and read each sentence of each instructions slowly and carefully. As always, remember the JFK Rule on the Email Etiquette handout: Before you ask someone else, ask what you have done to help yourself first.
Finally, DON’T FREAK OUT! The assignment is not designed to trick you. Everything you need is laid out for you. Follow the instructions step by step. The goal of the assignment as a final examination is for you to demonstrate what you know about world literature and why or how you know it. In other words, demonstrate that you have achieved the student learning outcomes as listed on our course syllabus:
This course also helps develop the general education skill of (1) critical/creative thinking; (2) communication; (3) cultural literacy; and (4) information and technical literacy.
STUDENT LEARNING OUTCOMES: (General Education Skills)
Students will be able to (the numbers in parentheses refer to the general education skills above):
Read critically, interpret and appreciate literary texts of multiple genres. (1)
Identify and explain how literary texts are relevant to their own experience and to the experiences of their own communities. (1, 3)
Explain how literary texts reflect and sometime challenge the historical, social and cultural contexts in which they are embedded. (1,3)
Write about literary texts at a college level. (1,2, 4)

Medication labeling

How to read the medication label

Do not forget to list your references in APA format for your original post and your reply to peers.
In order to safely administer medications, all nurses must understand how to read a drug label. Discuss the information that is found on a drug label. Find an image/picture of a drug label from the internet and identify all of the components on the drug label.

From your research, justify the importance of the preservation of evidence, and its role in the success of the defense or prosecution of the case. Provide a rationale to support your response and cite your sources.

Please respond to the following:
From your research, justify the importance of the preservation of evidence, and its role in the success of the defense or prosecution of the case. Provide a rationale to support your response and cite your sources.
Be sure to respond to at least one classmates post. Do you agree with your classmates perspective? Why or why not?

Respond to classmate in separate paragraph:

Chaqita Robinson
RE: Week 11 Discussion
The handling of digital evidence or any evidence for that matter is very important. Isolating and protecting digital evidence exactly as it is found without alteration to be analyzed by both the prosecution and defense team of the case. Collection is the gathering of devices and duplication of electronically stored information (ESI) for the purpose of preserving digital evidence (exact copy of the original) that remains untouched while digital forensics is performed. All digital evidence must be properly preserved and collected in accordance with forensic best practices. While collecting evidence from computer, one must know actually what they are doing. Any keystroke can cause the evidence to become altered, tampered and even destroyed. If not, the digital evidence may be inadmissible in court or spoliation sanctions may be imposed. Prosecution team uses the evidence to make their case to try to get a conviction; whereas as the defense team uses the evidence that has been collected to support a claim of their clients innocence. The creditability of the prosecutor and defense is at stake if there are any errors found while presenting the evidence during a trial.

I found the below source to be very helpful in understanding how digital evidence should be handled and to retrieve and preserve the evidence that is to be presented in trial for either the defense or prosecution team.

Digital Forensic Process—Preservation / Collection

Corruption and Ethics in Global Business

Corruption and Ethics in Global Business
Select a common ethical issue that may arise in the international business setting and find an article that discusses this issue in a news source, such as electronic newspapers, New York Times, International Business Times, Economic Times, or CNN News. Provide a summary of the article. Explain the root cause of these issues. Discuss how managers of international firms should address these issues.

Using the most common office visit, CPT code 99214, determine the reimbursement from the Centers for Medicare and Medicaid Services (online fee schedule available for Medicare).

Case Study: You are assessing the payerpatient mix for a health care organization. Currently, your payer mix is 40% Medicare, 10% Medicaid, 25% traditional indemnity insurance, 20% managed care, and 5% self-pay patients. Complete the following:

Using the most common office visit, CPT code 99214, determine the reimbursement from the Centers for Medicare and Medicaid Services (online fee schedule available for Medicare).

Using the same CPT code, 99214, determine the reimbursement for Medicaid (fee schedules should be available from the individual state).

Using the same CPT code, 99214, create at least 3 other traditional indemnity insurance reimbursements. If possible, use the actual reimbursement from the insurance carrier. It may be possible to obtain actual reimbursement information from your personal insurance carrier. If the information is not available, assume reimbursement by traditional indemnity insurance is usually 200% reimbursed more than Medicare and Medicaid, and managed care is usually 133% more than Medicare and Medicaid.

Compose an accounts receivable benchmark from this information showing columns for current, 3060, 6190, 90120, and greater than 120 days.

Assess the information for areas of improved reimbursement of at least 20% or more.

Evaluate the options available to change the payerpatient mix with consideration of related legal and ethical issues.

Propose a best strategy with justification and rationale based on effective decision-making tenets.

The body of the resultant paper should be 1012 pages. Spreadsheets demonstrating the accounts receivable analysis will be attached as appendices, and there will be at least 7 relevant peer-reviewed academic or professional references published within the past 5 years. Also attach appropriate fee schedules.

Explain why deception is the silver bullet that almost never misses (George & Bruce, 2014, p. 201). Develop a specific example to demonstrate your understanding.

Explain why deception is the silver bullet that almost never misses (George & Bruce, 2014, p. 201). Develop a specific example to demonstrate your understanding.
Please submit a substitutive initial post by midnight, Wednesday, supported with academic journal references, an intelligence example, and other appropriate material.