Fluent Essays

please complete the assignment template attached starting at page 8 and on. The information regarding the patient are on the pages before it and there is also a rubric attached for additional infoSOAP Note Template S: Subjective Information the patient or patient representative told you Initials: T.J. Age: Click or tap here to enter text. Gender: Female Height Weight BP HR RR Temp SPO2 Pain Rating Allergies (and reaction) 170cm 90kg 142/80 86 19 101.1F 99\% 7/10 Medication: Penicillin (rash/hives) Food: N/A Environment: Cats (itchy, eye redness, watery eyes) History of Present Illness (HPI) Chief Complaint (CC) Infected Right foot pain CC is a BRIEF statement identifying why the patient is here - in the patient’s own words - for instance headache, NOT bad headache for 3 days”. Sometimes a patient has more than one complaint. For example: If the patient presents with cough and sore throat, identify which is the CC and which may be an associated symptom O nset 1 week ago L ocation Ball of Right foot but also feels some pain in whole foot D uration 1 week ago. Pain worse 2 days ago, current pain level 7/10 C haracteristics Sharp and throbbing A ggravating Factors Walking and weight bearing R elieving Factors Tramadol and no weight bearing T reatment Taking pain medication, irrigate the wound, and apply a dry dressing Current Medications: Include dosage, frequency, length of time used and reason for use; also include OTC or homeopathic products. Medication (Rx, OTC, or Homeopathic) Dosage Frequency Length of Time Used Reason for Use Tramadol 50mg PO PRN 1 week Right foot pain Neosporin N/A PRN 1 week Right foot laceration Proventil 90mcg/spray Q4H PRN 2-3 puffs 25 years asthma Click or tap here to enter text. Click or tap here to enter text. Click or tap here to enter text. Click or tap here to enter text. Click or tap here to enter text. Past Medical History (PMHx) – Includes but not limited to immunization status (note date of last tetanus for all adults), past major illnesses, hospitalizations, and surgeries. Depending on the CC, more info may be needed. Diabetes, Asthma diagnosed at a young age, hypertension, tetanus shot (last year), up to date with immunizations, heavy menstrual periods, ER admit last week Social History (Soc Hx) - Includes but not limited to occupation and major hobbies, family status, tobacco and alcohol use, and any other pertinent data. Include health promotion such as use seat belts all the time or working smoke detectors in the house. Drugs: History of marijuana use. Stopped at age 20 or 21 due to asthma exacerbation Drinking: Socially drinks once or twice a week Smoking/Tobacco use: No Occupation: College student Family status: Lives with mother and younger sister Family History (Fam Hx) - Includes but not limited to illnesses with possible genetic predisposition, contagious or chronic illnesses. Reason for death of any deceased first degree relatives should be included. Include parents, grandparents, siblingIntroduction and Pre-brief In this graded assignment, you will interview Tina Jones to conduct a comprehensive health history and collect data to assess Ms. Jones’ recent right foot injury. You will have the opportunity to educate and empathize with Tina to engage in effective therapeutic communication; create a problem list using evidence from the data you collected; prioritize the identified problems to differentiate immediate from non-immediate care; and plan how to best address the most important concern with further assessment, interventions, and patient education. For this assignment, you will conduct a limited physical assessment. Your objective documentation must include a general statement and the findings for the skin (integumentary) body system. Purposes The purposes of the Shadow Health Physical Assessment Assignments are to: (a) increase knowledge and understanding of advanced practice physical assessment skills and techniques, (b) conduct focused and comprehensive histories and physical assessments for various patient populations, (c) adapt or modify your physical assessment skills and techniques to suit the individual needs of the patient, (d) apply assessment skills and techniques to gather subjective and objective data, (e) differentiate normal from abnormal physical examination findings, (f) summarize, organize, and appropriately document findings using correct professional terminology, (g) practice developing primary and differential diagnoses, (h) practice creating treatment plans which include diagnostics, medication, education, consultation/referral, and follow-up planning; and (i) analyze and reflect on own performance to gain insight and foster knowledge.   Activity Learning Outcomes Through this assignment, the student will demonstrate the ability to:  1. Apply knowledge and understanding of advanced practice physical assessment skills and techniques (CO1) 2. Perform focused and comprehensive histories and physical assessments for various patient populations (CO4 and CO5) 3. Adapt skills and techniques to suit the individual needs of the patient (CO4) 4. Differentiate normal from abnormal physical examination findings (CO2) 5. Summarize, organize, and document findings using correct professional terminology (CO3) 6. Reflect upon performance to gain insight and foster knowledge (CO1) Requirements NOTE: Before initiating any activity in Shadow Health, complete the required course weekly readings and lessons as well as review the introduction and pre-brief  On the Canvas Platform: 1. Summarize, organize, and appropriately document findings using correct professional terminology on the SOAP Note Template. 2. Document a comprehensive problem list based upon the history and physical examination findings on the SOAP Note Template. 3. Provide rationales and citations for diagnoses and interventions for the brief treatment plan. 4. Include at least one scholarly source to support diagnoses and treatment interventions with rationa