DUE FRIDAY NOVEMBER 4

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Patients are frequently uncomfortable discussing with healthcare professional’s issues that involve the genitalia and rectum; however, gathering an adequate history and properly conducting a physical exam are vital. Examining case studies of genital and rectal abnormalities can help prepare advanced practice nurses to accurately assess patients with problems in these areas.

In this Lab Assignment, you will analyze an Episodic note case study that describes abnormal findings in patients seen in a clinical setting. You will consider what history should be collected from the patients, as well as which physical exams and diagnostic tests should be conducted. You will also formulate a differential diagnosis with several possible conditions.

 

  • Review the Episodic note case study your instructor provides you for this week’s Assignment. Please see the “Course Announcements” section of the classroom for your Episodic note case study.
  • Based on the Episodic note case study:
    • Review this week’s Learning Resources, and consider the insights they provide about the case study. Refer to Chapter 3 of the Sullivan resource to guide you as you complete your Lab Assignment.
    • Search the Walden library or the Internet for evidence-based resources to support your answers to the questions provided.
    • Consider what history would be necessary to collect from the patient in the case study.
    • Consider what physical exams and diagnostic tests would be appropriate to gather more information about the patient’s condition. How would the results be used to make a diagnosis?
    • Identify at least five possible conditions that may be considered in a differential diagnosis for the patient.

Using evidence-based resources from your search, answer the following questions and support your answers using current evidence from the literature.

  • Analyze the subjective portion of the note. List additional information that should be included in the documentation.
  • Analyze the objective portion of the note. List additional information that should be included in the documentation.
  • Is the assessment supported by the subjective and objective information? Why or why not?
  • Would diagnostics be appropriate for this case, and how would the results be used to make a diagnosis?
  • Would you reject/accept the current diagnosis? Why or why not? Identify three possible conditions that may be considered as a differential diagnosis for this patient. Explain your reasoning using at least three different references from current evidence-based literature.
  1. Case Study Assignment This week you will be reviewing another SOAP note and reflecting on the additional information that you would be needing.  This is not in SOAP format, you will use headings for each section, and give me dialogue on what information is missing in each section.  You will provide 5 differentials and reflect on the questions posed for the assignment.  Be sure to support with scholarly references.

Week 10: Special Examinations—Breast, Genital, Prostate, and Rectal GENITALIA ASSESSMENT

Subjective:•

CC: “I have bumps on my bottom that I want to have checked out.”

  • HPI: AB, a 21-year-old WF college student reports to your clinic with external bumps on her genital area. She states the bumps are painless and feel rough. She states she is sexually active and has had more than one partner during the past year. Her initial sexual contact occurred at age 18. She reports no abnormal vaginal discharge. She is unsure how long the bumps have been there but noticed them about a week ago. Her last Pap smear exam was 3 years ago, and no dysplasia was found; the exam results were normal. She reports one sexually transmitted infection (chlamydia) about 2 years ago. She completed the treatment for chlamydia as prescribed.
  • PMH: Asthma•Medications: Symbicort 160/4.5mcg •Allergies: NKDA
  • FH: No hx of breast or cervical cancer, Father hx HTN, Mother hx HTN, GERD
  • Social: Denies tobacco use; occasional etoh, married, 3 children (1 girl, 2 boys)

Objective:•VS: Temp 98.6; BP 120/86; RR 16; P 92; HT 5’10”; WT 169lbs•Heart: RRR, no murmurs•Lungs: CTA, chest wall symmetrical•Genital: Normal female hair pattern distribution; no masses or swelling. Urethral meatus intact without erythema or discharge. Perineum intact. Vaginal mucosa pink and moist with rugae present, pos for firm, round, small, painless ulcer noted on external labia•Abd: soft, normoactive bowel sounds, neg rebound, neg murphy’s, neg McBurney•Diagnostics: HSV specimen obtained

Assessment:•Chancre

PLAN: This section is not required for the assignments in this course (NURS 6512) but will be required for future course

In summary, be sure to follow the rubric for this assignment.  Tell me what is missing in each section…..and would you support or refute the diagnosis.  Support that answer with rationale, and provide differential diagnosis with supported rationale.  Utilize scholarly references to support your rationales.  Remember….if you are doing a focused exam, which is what these case studies are…..be sure to really expand on the body systems that you are concerned about to hone in on your differential diagnosis.  This will help you with your documentation completeness going forward.

Due 10-27

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20-year-old male complains of experiencing intermittent headaches. The headaches diffuse all over the head, but the greatest intensity and pressure occurs above the eyes and spreads through the nose, cheekbones, and jaw.

 

·         your Case Study Assignment should be in the Episodic/Focused SOAP Note format rather than the traditional narrative style format. Refer to Chapter 2 of the Sullivan text and the Episodic/Focused SOAP Template in the Week 5 Learning Resources for guidance. Remember that all Episodic/Focused SOAP notes have specific data included in every patient case.

With regard to the case study you were assigned:

·         Review this week’s Learning Resources, and consider the insights they provide about the case study.

·         Consider what history would be necessary to collect from the patient in the case study you were assigned.

·         Consider what physical exams and diagnostic tests would be appropriate to gather more information about the patient’s condition. How would the results be used to make a diagnosis?

·         Identify at least five possible conditions that may be considered in a differential diagnosis for the patient.

 

Use the Episodic/Focused SOAP Template and create an episodic/focused note about the patient in the case study to which you were assigned using the episodic/focused note template provided in the Week 5 resources. Provide evidence from the literature to support diagnostic tests that would be appropriate for each case. List five different possible conditions for the patient’s differential diagnosis, and justify why you selected each. 

discussion response

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Respond to your colleagues assigned different case studies than you. Analyze the possible conditions from your colleagues’ differential diagnoses. Determine which of the conditions you would reject and why. Identify the most likely condition, and justify your reasoning.

 

 

SB, 46, Female, Caucasian

CC (chief complaint): Right Ankle Pain

HPI: A 46-year-old Caucasian woman experiences discomfort in both ankles, but her right ankle pain—which is non-radiating—is more concerning. When playing soccer three days ago, she heard a “pop” sound. She claims that while she can support weight, it hurts. The right ankle is described as throbbing and aching 7/10 with persistent pain, while the left ankle only aches and is in 2/10 of discomfort. The patient states the pain is tolerable with intermittent ice and 600 mg of ibuprofen every six hours. She claims the discomfort becomes intolerable if she stays upright for a prolonged period.

Further inquiries for the patient:

Where is the discomfort in the ankle? Can you give your pain a 0–10 rating? Have you made any attempts to lessen the pain? What could possibly make the agony worse? How long have your two ankles been hurting? Have either of your ankles ever been hurt before?

Current Medications:  Daily multivitamin

Ibuprofen 600mg every six hours for ankle pain for the last three days

Allergies:  no allergies to food, drugs, or environmental

PMHx:   Stage 1 hypertension was diagnosed 4 years ago, not using any drugs, well managed with diet and exercise, immunizations current, latest tetanus shot at age 40, flu shot in August 2022.

Surgeries: Hysterectomy at age 21.Social Hx:    S.B. is a history student who enjoys coaching and playing girls’ soccer. She hasn’t had any siblings and has been married for ten years. They have a boy and a girl, ages 27 and 29, respectively. She enjoys going on family hikes, works out three days a week, coaches soccer during the week, and plays soccer with friends and family on the weekends. Denies using smoke or illegal drugs but does enjoy one or two glasses of wine with colleagues on the weekends. She reportedly eats a low-fat diet and was active up until the weekend before she was hurt.

Family History:  

Mother 68-year-old diabetic and HTN

 Father still living with colon cancer at 70.

 Maternal Grandmother passed away from heart failure at the age of 77.

Maternal Grandfather’s death was an MVA at age 65.

paternal grandmother diabetic grandma who is still living at age 88

paternal grandfather 80-year-old stroke

Son, healthy and 27-year-old

Daughter, age 29, is in good health.

ROS:

GENERAL:  There are no weariness, weakness, or weight loss symptoms. Skin denies having a rash or itching.

HEENT:  Eyes:  The patient disputes any head trauma. The patient denies lesions, sores, redness, discomfort, dysphagia, hoarseness, and sore throat in the mouth and throat.

SKIN:  The patient denies having pruritus, urticaria, or rashes. The right lateral ankle is bruised, according to the patient.

CARDIOVASCULAR:  denies feeling pressure, pain, or discomfort in the chest. denies edema and palpitations.

RESPIRATORY:  denies feeling discomfort or pain in the chest. denies having edema or palpitations.

GASTROINTESTINAL:  No vomiting, diarrhea, or anorexia. neither blood nor abdominal pain.

GENITOURINARY:  urination with burning. Pregnancy. Menstrual cycle date, 09/08/2023

NEUROLOGICAL:  No throbbing headache, fainting spells, syncope, ataxia, paralysis, or tingling or numbness in the extremities. No modification to bladder or bowel control.

HEMATOLOGIC:  There is no bruising, bleeding, or anemia.

LYMPHATICS:  There are no swollen nodes. splenectomy has never been an event.

PSYCHIATRIC:  denies depression or anxiety.

ENDOCRINOLOGIC:  No reports of cold, heat, or sweating. not, having polydipsia or polyuria

ALLERGIES: No history of asthma, hives, eczema, or rhinitis.

MUSCULOSKELETAL:  The right ankle is reportedly tight and erythematous. Reduced range of motion and weight bearing; denial of radiating pain from the right foot; denial of symptoms of mild aches in the left foot.

Vitals BP 135/85, heart rate 65, respiration 16, temperature 97.5 oxygen sats 97% on room air

General: alert and oriented x4, sitting on exam table well-dressed cooperative, does not appear to be in acute distress, good posture while sitting, unsteady gait limping on the right foot when ambulating, able to provide history.

Skin: Skin is warm, dry, and intact right ankle positive for erythema swelling tenderness, and stiffness and 3×3.5cm ecchymosis on mid-lateral malleolus area left ankle with mild tenderness no swelling or erythema.

Respiratory: Symmetric; no utilization of auxiliary muscles; all lobes produce CTA sounds.

Cardiovascular: Heart rate and rhythm are regular, S1 and S2 heart sounds are audible, no additional heart sounds are present, distal pulses are bilaterally 2+, edema is noticed at the right ankle, and leg hair distribution is normal.

Musculoskeletal: Asymmetry between the ankle and foot on the right and left. Non-pitting edema and ecchymosis in the mid-lateral malleolus area of the right ankle. Midline of the Achilles tendon. Ankle discomfort on the right lower extremity is rated 7/10. There is tenderness to the touch on the lateral side of the ankle, across the anterior talofibular ligament. Positive for discomfort throughout range of motion, with limitation indicated during dorsiflexion, 5 plantar flexion, and inversion. Skin is undamaged. Weight-bearing on the left ankle with 2/10 minor pain and no erythema or swelling. Moving caused the right ankle’s pain and stiffness to worsen when it was bearing weight. There is no crepitus, deformity, or bony soreness.

Diagnostic results:

Anterior draw test: positive

 Talar tilt test: Anterior talofibular ligament reacted positively to pain.

The screening test for lateral ankle sprain and probable ATFL injuries, the anterior draw test, revealed a positive result in this patient (Gomes et al., 2018). With their knee flexed to counteract the pull of their gastrocnemius and soleus muscles and their foot supported perpendicular to the leg, the patient sits at the end of the bed or lies face down for the ankle drawer test. The examiner grasps around the heel with one hand and stabilizes the tibia from the anterior side with the other while maintaining the ankle joint at 10 to 15° of plantar flexion. The examiner pulls the heel forward while continuing to stabilize the tibia with the other hand after urging the patient to relax their muscles. If the patient expresses pain, the test is positive, and the examiner watches the patient for a reaction. A positive sign is generated by moving the ankle through abduction and adduction while the practitioner listens for a cluck or a pain reaction from the patient in the Talar tilt test, which is also used to assess the calcaneofibular ligament. Both tests must be finished within 24-48 hours for the highest level of accuracy (Gomes et al., 2018).

The Ottawa ankle rule needs to be applied to this patient’s case, and it needs to be analyzed and examined to see if an MRI is necessary. Both the anterior draw test and the talar tilt test returned favorable results for the patient. The Ottawa rule states that a patient can help detect nearly 100% fractures while significantly reducing the number of unnecessary radiographs if they exhibit any of the following symptoms: pain at the base of the fifth metatarsal, tenderness at the posterior edge or tip of the medial or lateral malleolus, inability to bear weight taking four steps either immediately after the injury or in the clinic. (Lynch, 2002).

X-ray: If the patient’s ankle radiograph is normal, the examiner may proceed to further procedures, such as the squeeze test, crossed-leg test, and external rotation test, to grade the sprain and evaluate the tendons and ligaments in the affected extremity.

 A.

 Differential Diagnoses

A more serious injury involving an incomplete ligament tear is an ankle sprain (grade II sprain). Patients have mild joint pain, ecchymosis, swelling, and tenderness. On examination, the patient will show mild to severe joint instability, a limited range of motion, and functional loss. The sufferer is in discomfort as they walk. 2019 (Maughan)

Inflammation of the Achilles tendon is known as Achilles tendonitis. Where the tendon attaches to the calcaneus, this inflammation causes pain and swelling as symptoms. The patient complains of ankle tightness, which makes jogging and walking challenging (Baumann, et al., 2016).  S.B. patients reported soreness and tenderness in the mid-lateral area of the ankle. Feel the back of the ankle to check for Achilles swelling.

A middle-aged or older adult who complains of ankle pain may have calcaneal bursitis. Wearing firm shoes, such as soccer shoes, might result in bursitis by rubbing against the heel where the Achilles tendon inserts. Identify the retrocalcaneal bursa and feel the ankle for tenderness that could be a sign of bursitis to see if this might be the issue (Boggess & Maughan, 2019).

According to the American Academy of Orthopedic Surgeons (2013), an ankle fracture can affect one or more of the ankle bones, including the tibia, fibula, posterior malleolus, and talus. Symptoms of an ankle fracture include intense pain that worsens quickly, swelling, bruising, soreness, deformity, and the inability to bear weight. Because a fracture might make it difficult to bear weight and may result in an ankle deformity, the patient may hear a popping sound.

Anterior impingement, commonly referred to as a footballer’s ankle, is a disorder that causes pain, swelling, and a reduction in the overall ankle range of motion, primarily affecting dorsiflexion (Vaseenon & Amendola, 2012).

References

American Academy of Orthopedic Surgeons. (2013). Ankle Fractures. Retrieved from https://orthoinfo.aaos.org/en/diseases–conditions/ankle-fractures-broken-ankle/ 

Baumann, L. C., Dains, J. E., & Scheibel, P. (2016). Advanced health assessment and clinical diagnosis in primary care (5th ed.). St. Louis, MO: Elsevier Mosby

Boggess, B. R., & Maughan, K. L. (2019). Achilles tendinopathy and tendon rupture.  https://www.uptodate.com/contents/achilles-tendinopathy-and-tendon-rupture? search=Achilles tendon rupture&source=search_result&selectedTitle=1~34&usage_type=default&display _rank=1#H13 

Lynch S. A. (2002). Assessment of the Injured Ankle in the Athlete. Journal of Athletic Training, 37(4), 406–412.

Maughan, K. L. (2019). Ankle sprain. https://www.uptodate.com/contents/anklesprain?search=ankle sprain&sourc e=search_result&selectedTitle=1~38&usage_type=default&display_rank=

Tu, P. (2018). Heel Pain: Diagnosis and Management. https://www.aafp.org/afp/2018/0115/p86.html

Vaseenon, T., & Amendola, A. (2012). Update on anterior ankle impingement. Current reviews in musculoskeletal medicine, 5(2), 145–150. https://doi.org/10.1007/s12178-012-9117-z

 

 

 

Discussion response I

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Respond to your peers post

 

 

Episodic/Focused SOAP Note Template

SB, 46, Female, Caucasian

CC (chief complaint): Right Ankle Pain

HPI: A 46-year-old Caucasian woman experiences discomfort in both ankles, but her right ankle pain—which is non-radiating—is more concerning. When playing soccer three days ago, she heard a “pop” sound. She claims that while she can support weight, it hurts. The right ankle is described as throbbing and aching 7/10 with persistent pain, while the left ankle only aches and is in 2/10 of discomfort. The patient states the pain is tolerable with intermittent ice and 600 mg of ibuprofen every six hours. She claims the discomfort becomes intolerable if she stays upright for a prolonged period.

Further inquiries for the patient:

Where is the discomfort in the ankle? Can you give your pain a 0–10 rating? Have you made any attempts to lessen the pain? What could possibly make the agony worse? How long have your two ankles been hurting? Have either of your ankles ever been hurt before?

Current Medications:  Daily multivitamin

Ibuprofen 600mg every six hours for ankle pain for the last three days

Allergies:  no allergies to food, drugs, or environmental

PMHx:   Stage 1 hypertension was diagnosed 4 years ago, not using any drugs, well managed with diet and exercise, immunizations current, latest tetanus shot at age 40, flu shot in August 2022.

Surgeries: Hysterectomy at age 21.Social Hx:    S.B. is a history student who enjoys coaching and playing girls’ soccer. She hasn’t had any siblings and has been married for ten years. They have a boy and a girl, ages 27 and 29, respectively. She enjoys going on family hikes, works out three days a week, coaches soccer during the week, and plays soccer with friends and family on the weekends. Denies using smoke or illegal drugs but does enjoy one or two glasses of wine with colleagues on the weekends. She reportedly eats a low-fat diet and was active up until the weekend before she was hurt.

Family History:  

Mother 68-year-old diabetic and HTN

 Father still living with colon cancer at 70.

 Maternal Grandmother passed away from heart failure at the age of 77.

Maternal Grandfather’s death was an MVA at age 65.

paternal grandmother diabetic grandma who is still living at age 88

paternal grandfather 80-year-old stroke

Son, healthy and 27-year-old

Daughter, age 29, is in good health.

ROS:

GENERAL:  There are no weariness, weakness, or weight loss symptoms. Skin denies having a rash or itching.

HEENT:  Eyes:  The patient disputes any head trauma. The patient denies lesions, sores, redness, discomfort, dysphagia, hoarseness, and sore throat in the mouth and throat.

SKIN:  The patient denies having pruritus, urticaria, or rashes. The right lateral ankle is bruised, according to the patient.

CARDIOVASCULAR:  denies feeling pressure, pain, or discomfort in the chest. denies edema and palpitations.

RESPIRATORY:  denies feeling discomfort or pain in the chest. denies having edema or palpitations.

GASTROINTESTINAL:  No vomiting, diarrhea, or anorexia. neither blood nor abdominal pain.

GENITOURINARY:  urination with burning. Pregnancy. Menstrual cycle date, 09/08/2023

NEUROLOGICAL:  No throbbing headache, fainting spells, syncope, ataxia, paralysis, or tingling or numbness in the extremities. No modification to bladder or bowel control.

HEMATOLOGIC:  There is no bruising, bleeding, or anemia.

LYMPHATICS:  There are no swollen nodes. splenectomy has never been an event.

PSYCHIATRIC:  denies depression or anxiety.

ENDOCRINOLOGIC:  No reports of cold, heat, or sweating. not, having polydipsia or polyuria

ALLERGIES: No history of asthma, hives, eczema, or rhinitis.

MUSCULOSKELETAL:  The right ankle is reportedly tight and erythematous. Reduced range of motion and weight bearing; denial of radiating pain from the right foot; denial of symptoms of mild aches in the left foot.

Vitals BP 135/85, heart rate 65, respiration 16, temperature 97.5 oxygen sats 97% on room air

General: alert and oriented x4, sitting on exam table well-dressed cooperative, does not appear to be in acute distress, good posture while sitting, unsteady gait limping on the right foot when ambulating, able to provide history.

Skin: Skin is warm, dry, and intact right ankle positive for erythema swelling tenderness, and stiffness and 3×3.5cm ecchymosis on mid-lateral malleolus area left ankle with mild tenderness no swelling or erythema.

Respiratory: Symmetric; no utilization of auxiliary muscles; all lobes produce CTA sounds.

Cardiovascular: Heart rate and rhythm are regular, S1 and S2 heart sounds are audible, no additional heart sounds are present, distal pulses are bilaterally 2+, edema is noticed at the right ankle, and leg hair distribution is normal.

Musculoskeletal: Asymmetry between the ankle and foot on the right and left. Non-pitting edema and ecchymosis in the mid-lateral malleolus area of the right ankle. Midline of the Achilles tendon. Ankle discomfort on the right lower extremity is rated 7/10. There is tenderness to the touch on the lateral side of the ankle, across the anterior talofibular ligament. Positive for discomfort throughout range of motion, with limitation indicated during dorsiflexion, 5 plantar flexion, and inversion. Skin is undamaged. Weight-bearing on the left ankle with 2/10 minor pain and no erythema or swelling. Moving caused the right ankle’s pain and stiffness to worsen when it was bearing weight. There is no crepitus, deformity, or bony soreness.

Diagnostic results:

Anterior draw test: positive

 Talar tilt test: Anterior talofibular ligament reacted positively to pain.

The screening test for lateral ankle sprain and probable ATFL injuries, the anterior draw test, revealed a positive result in this patient (Gomes et al., 2018). With their knee flexed to counteract the pull of their gastrocnemius and soleus muscles and their foot supported perpendicular to the leg, the patient sits at the end of the bed or lies face down for the ankle drawer test. The examiner grasps around the heel with one hand and stabilizes the tibia from the anterior side with the other while maintaining the ankle joint at 10 to 15° of plantar flexion. The examiner pulls the heel forward while continuing to stabilize the tibia with the other hand after urging the patient to relax their muscles. If the patient expresses pain, the test is positive, and the examiner watches the patient for a reaction. A positive sign is generated by moving the ankle through abduction and adduction while the practitioner listens for a cluck or a pain reaction from the patient in the Talar tilt test, which is also used to assess the calcaneofibular ligament. Both tests must be finished within 24-48 hours for the highest level of accuracy (Gomes et al., 2018).

The Ottawa ankle rule needs to be applied to this patient’s case, and it needs to be analyzed and examined to see if an MRI is necessary. Both the anterior draw test and the talar tilt test returned favorable results for the patient. The Ottawa rule states that a patient can help detect nearly 100% fractures while significantly reducing the number of unnecessary radiographs if they exhibit any of the following symptoms: pain at the base of the fifth metatarsal, tenderness at the posterior edge or tip of the medial or lateral malleolus, inability to bear weight taking four steps either immediately after the injury or in the clinic. (Lynch, 2002).

X-ray: If the patient’s ankle radiograph is normal, the examiner may proceed to further procedures, such as the squeeze test, crossed-leg test, and external rotation test, to grade the sprain and evaluate the tendons and ligaments in the affected extremity.

 A.

 Differential Diagnoses

A more serious injury involving an incomplete ligament tear is an ankle sprain (grade II sprain). Patients have mild joint pain, ecchymosis, swelling, and tenderness. On examination, the patient will show mild to severe joint instability, a limited range of motion, and functional loss. The sufferer is in discomfort as they walk. 2019 (Maughan)

Inflammation of the Achilles tendon is known as Achilles tendonitis. Where the tendon attaches to the calcaneus, this inflammation causes pain and swelling as symptoms. The patient complains of ankle tightness, which makes jogging and walking challenging (Baumann, et al., 2016).  S.B. patients reported soreness and tenderness in the mid-lateral area of the ankle. Feel the back of the ankle to check for Achilles swelling.

A middle-aged or older adult who complains of ankle pain may have calcaneal bursitis. Wearing firm shoes, such as soccer shoes, might result in bursitis by rubbing against the heel where the Achilles tendon inserts. Identify the retrocalcaneal bursa and feel the ankle for tenderness that could be a sign of bursitis to see if this might be the issue (Boggess & Maughan, 2019).

According to the American Academy of Orthopedic Surgeons (2013), an ankle fracture can affect one or more of the ankle bones, including the tibia, fibula, posterior malleolus, and talus. Symptoms of an ankle fracture include intense pain that worsens quickly, swelling, bruising, soreness, deformity, and the inability to bear weight. Because a fracture might make it difficult to bear weight and may result in an ankle deformity, the patient may hear a popping sound.

Anterior impingement, commonly referred to as a footballer’s ankle, is a disorder that causes pain, swelling, and a reduction in the overall ankle range of motion, primarily affecting dorsiflexion (Vaseenon & Amendola, 2012).

References

American Academy of Orthopedic Surgeons. (2013). Ankle Fractures. Retrieved from https://orthoinfo.aaos.org/en/diseases–conditions/ankle-fractures-broken-ankle/ 

Baumann, L. C., Dains, J. E., & Scheibel, P. (2016). Advanced health assessment and clinical diagnosis in primary care (5th ed.). St. Louis, MO: Elsevier Mosby

Boggess, B. R., & Maughan, K. L. (2019). Achilles tendinopathy and tendon rupture.  https://www.uptodate.com/contents/achilles-tendinopathy-and-tendon-rupture? search=Achilles tendon rupture&source=search_result&selectedTitle=1~34&usage_type=default&display _rank=1#H13 

Lynch S. A. (2002). Assessment of the Injured Ankle in the Athlete. Journal of Athletic Training, 37(4), 406–412.

Maughan, K. L. (2019). Ankle sprain. https://www.uptodate.com/contents/anklesprain?search=ankle sprain&sourc e=search_result&selectedTitle=1~38&usage_type=default&display_rank=

Tu, P. (2018). Heel Pain: Diagnosis and Management. https://www.aafp.org/afp/2018/0115/p86.html

Vaseenon, T., & Amendola, A. (2012). Update on anterior ankle impingement. Current reviews in musculoskeletal medicine, 5(2), 145–150. https://doi.org/10.1007/s12178-012-9117-z

THIS CANNOT BE LATE (Discussion week 8)

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To prepare:

  • By Day 1 of this week, you will be assigned to one of the following specific case studies for this Discussion. Please see the “Course Announcements” section of the classroom for your assignment from your Instructor.
  • Your Discussion post should be in the Episodic/Focused SOAP Note format rather than the traditional narrative style Discussion posting format. Refer to Chapter 2 of the Sullivan text and the Episodic/Focused SOAP Template in the Week 5 Learning Resources for guidance. Remember that all Episodic/Focused SOAP notes have specific data included in every patient case.
  • Review the following case studies:

Case 1: Back Pain

A 42-year-old male reports pain in his lower back for the past month. The pain sometimes radiates to his left leg. In determining the cause of the back pain, based on your knowledge of anatomy, what nerve roots might be involved? How would you test for each of them? What other symptoms need to be explored? What are your differential diagnoses for acute low back pain? Consider the possible origins using the Agency for Healthcare Research and Quality (AHRQ) guidelines as a framework. What physical examination will you perform? What special maneuvers will you perform?

 

 

With regard to the case study you were assigned:

  • Review this week’s Learning Resources, and consider the insights they provide about the case study.
  • Consider what history would be necessary to collect from the patient in the case study you were assigned.
  • Consider what physical exams and diagnostic tests would be appropriate to gather more information about the patient’s condition. How would the results be used to make a diagnosis?
  • Identify at least five possible conditions that may be considered in a differential diagnosis for the patient.
  • Note:When you submit your initial post, please include a header as the first line indicating your assigned case study. For example, “Review of Case Study ___.” Fill in the blank with the number of the case study you were assigned.

The American Dating Culture

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Whether you’re looking for a lifestyle lover or just to had fun, dating can be difficult and nuanced. It calls for empty conversation, self-awareness, and compassion. Seeing customs vary across America depending on the region, cultural traditions, and church. These variations create a dynamic dating environment that calls for more clearness and understanding, along with societal changes and changing gender dynamics.

Americans are typically more receptive than ever to dating persons from a variety of backgrounds and life experience. The vast majority of singles claim that they would be open to dating anyone who practices a different religion or is of another race or ethnicity than themselves. Additionally, the majority of Americans are willing to date someone who has a illness or who earns significantly more money than they do.

Nevertheless, there is still much work to be done to dismantle prejudice and bias in the dating world. The majority of American grownups claim that when looking for a deadline, they have encountered some sort of harassment or discrimination https://mail-order-bride.com/blog/top-russian-cities-with-the-best-brides. These experiences have occasionally been serious and tragic. Even worse, some folks have been attacked while out on a time. In other instances, the abuser was a member of the victim’s possess household.

Despite this, dating is still more of a personal decision in the United States than it is in other nations. In actuality, men are more likely to request ladies out on schedules than the other way around. Colonists are also more likely to be open to dating a male who practices another religion or who is disabled. Numerous changes in dating customs have resulted from the# Metoo movement. While some of these adjustments are good, others are bad. For instance, many people have claimed that in the period of physical abuse and wrongdoing, it is more difficult for them to know how to act on dates.

How individuals choose where to go on a second date and who should pay is another significant change in how citizens date in America. If you are fresh to the nation and its dating culture, these queries can be extremely nerve-wracking.

In the us, pubs, coffee shops, and franchises are the most well-liked locations to meet somebody for a first time. Meeting at job or at a friend’s house is also more comfortable for some people. It’s crucial to look someone in the attention while you’re speaking. This demonstrates your interest in them and your attention to detail.

Having a friend or woman can been beneficial for people who are unfamiliar with American dating customs. This friend makes sure you look your best, keeps the conversation going, and helps you meet new people. This word may get common to you if you enjoy the television program How I Met Your Family.

How to achieve success in an International Matrimony

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It’s not always simple to marry someone from a diverse culture. Even though the problems and difficulties that arise can be challenging, there are solutions mail order bride online.

It’s critical to comprehend the laws of the nation where you’re getting married and how they relate to your particular circumstance click this link here now. Legal, visa, and economic issues that may arise in global union will be covered in this article.

Legal Concerns

International marriages does read what he said require complicated legal issues and call for specialized guidance. For instance, the process of dissolving a marriage may become very difficult if you marry someone who is from an extremely unique country.

In general, a union is only deemed acceptable in the united states if it abides by its laws and satisfies certain criteria. Polygamous relationships, civil unions, private partnerships that do not meet the definition of matrimony, substitute marriages in which one party was not present for the festival, and matrimony entered into for immigration purposes ( review The Proposal with Sandra Bullock or Greencard with Gerard Depardieu for some superb movies on this subject ) are some of the overseas marriage types that are not accepted in the united states.

It’s crucial to speak with a lawyer who can give you certain guidance on the nations involved and your particular situation. This likely cover topics related to immigration and visa applications. The lawyer is also discuss potential effects of these problems on property tier.

Dilemmas with Visas

Before you get married, it’s crucial that your fiancé is lawfully able to enter the country. This includes making sure all prior spouses have been legally ended, which perhaps call for the filing of standard dying or breakup diplomas. Additionally, you’ll need to demonstrate that your new marriage is legitimate and was n’t entered into solely to obtain U.s. residency ( review Gerard Depardieu’s The Proposal or Greencard for an entertaining look at this con) ).

You can sponsor your spouse to apply for an adjustment of standing to become a lawful permanent resident of the united states if they are already there for labor or visitor reasons. Nonetheless, this approach will keep you and your spouse apart, which can take some time. To ensure that the process is carried out correctly and on schedule, it is crucial to seek assistance. This is especially true if you’re utilizing a union brokerage services to sponsor your visa.

monetary problems

Intricate monetary problems may result from international matrimony. When partners have acquired house under various legal governments in various nations or says, for instance, property law may be difficult. Judges have had difficulty resolving these issues. Some people have adopted a” overall atomicity” strategy, according to which the property law of the website state governs all of an individual couple’s assets regardless of where and when they were acquired.

A choice-of-law section stating which county’s home law they wish to maintain in the event of a divorce can also be included by couples in their marital agreement. Unless they are found to been ambiguous or inconsistent with post common scheme, American judges typically enforce like contracts.

Finally, it’s crucial to exercise caution when dealing with the possibility of scams. By pressuring their unsuspecting families to get married right away and demanding money, some dishonest boyfriends will attempt to seduce them into an international union. If you notice any of these warning symptoms in your relationship, pursue assistance.

Obtaining the Relationship License

Getting married to someone who is from another region has a number of difficulties. It can be challenging to navigate the multiculturalism process, establish citizen, and settle house problems. Couples really seek constitutional counsel and assistance before beginning this quest.

Through a procedure known as “adjustment of rank,” someone who is already in the united states on an American card does convert it to another kind of natural card. This is complicated and necessitates extensive evidence. To find out more about the needs for their particular area, the few may get in touch with the acceptable official or tourist information business.

There is no national register for relationships in the united states, whether they are domestic or foreign. It does, yet, accept relationships that take place in various nations as long as they are enforceable by the legislation of that nation or state. For instance, residency and another requirements must be met before a couple can get married in Turkey. This can sometimes involve getting a notarized petition from the regional government stating they are qualified to get married.

Week 6 assignment 1 DUE OCTOBER 7, 2023

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  1. In this Assessment 1 Assignment, you will analyze an Episodic Note case study that describes abnormal findings in patients seen in a clinical setting. This is in a scholarly paper format and not SOAP format this week. You will consider what history should be collected from the patients, as well as which physical exams and diagnostic tests should be conducted. You will also formulate a differential diagnosis with several possible conditions. Follow the rubric…..Be sure to use APA format…..and upload by Day 7.

Subjective:•CC: “My stomach hurts, I have diarrhea and nothing seems to help.”•HPI: JR, 47 yo WM, complains of having generalized abdominal pain that started 3 days ago. He has not taken any medications because he did not know what to take. He states the pain is a 5/10 today but has been as much as 9/10 when it first started. He has been able to eat, with some nausea afterwards.•PMH: HTN, Diabetes, hx of GI bleed 4 years ago •Medications: Lisinopril 10mg, Amlodipine 5 mg, Metformin 1000mg, Lantus 10 units qhs•Allergies: NKDA•FH: No hx of colon cancer, Father hx DMT2, HTN, Mother hx HTN, Hyperlipidemia, GERD •Social: Denies tobacco use; occasional etoh, married, 3 children (1 girl, 2 boys)

Objective:•VS: Temp 99.8; BP 160/86; RR 16; P 92; HT 5’10”; WT 248lbs•Heart: RRR, no murmurs•Lungs: CTA, chest wall symmetrical•Skin: Intact without lesions, no urticaria •Abd: soft, hyperactive bowel sounds, pos pain in the LLQ•Diagnostics: None

Assessment:•Left lower quadrant pain •Gastroenteritis

PLAN: This section is not required for the assignment.

 

One last thought for the week on Academic Integrity…..I urge you to review the Walden Policy on this.  This is taken very seriously.  Please paraphrase, and place documents in your own words.  I assure you….this is watched closely, so do not be tempted to use other peoples work, as you will be in violation of this policy!

How to create a Successful Long-distance Relationship

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It’s challenging to create long-distance relationships. It requires commitment https://mail-order-brides-guide.com/mail-order-bride-sites/review-date-asian-woman-site/, intelligent conversation, and a whole lot of effort!

By incorporating them into routine activities, make them feel like a part of your life despite the distance. For example, ask their opinion on a choice you’re making or request their advice on a trouble visit this site right here you’re facing.

1. Be open and honest

Long-distance relationships their explanation typically require open and honest communication, as all connections do. There are some points that are particular to Ldrs that can make it more difficult to connect successfully, though.

For starters, you might discover that your mate responses url or acts in ways that irritate or annoy you, especially at the beginning of a marriage. When these things happen, it’s important to speak up rather than just assume they’re hiding everything or trying to intimidate you.

Additionally, you must become open and honest with your mate read here regarding what you want from the relation. This includes whether you want to live far away from home or if you’re willing to engage in a physical connection. To maintain a goal-oriented marriage, it is also beneficial to have a forthcoming explore scheduled.

2. Set practical aspirations

Long distance relationships may be demanding, but they can also be actually fulfilling. It all depends on your willingness to put in the necessary job and anticipation visit this site.

It’s important to examine those expectations with your lover as soon as possible, for instance, if you anticipate them to word you back right away or contact you whenever you’re together. This will stop miscommunications and annoyance after.

Ldrs demand more work than localized relationships, which is another important factor to keep in mind. This can include issues like making certain you talk regularly, setting goals for the future, and avoiding prevalent velocity pimples, for as resentment. Make sure you and your companion comprehend the five love languages— words of affirmation, acts of service, receiving gifts, quality time, and actual touch – to help strengthen your relationship.

3. Create shared experience

Long-distance ties call for a particular degree of dedication from both partners. This might be materially or in terms of changing routine programs to create moment for each other. Yet, the benefits can be well worth the sacrifice.

In any relationship, prioritizing communication is essential, but it becomes even more important when communicating over a long length. Use ordinary phone or video invites as well as text messages to maintain a strong link.

When you actually have the opportunity to devote time collectively, make plans for events or adventures that last and foster connection. Observe a film that you both love, for instance, and talk about it as though you were sitting next to each other. This can be a enjoyable way to stay connected and develop friendships over common passions.

4. Promote each another

More work and care are required for long-distance connections than for regional versions. They even give users the chance to have similar views and give priority to one another.

If you and your spouse like to communicate generally, make it a priority. It may be beneficial to set up a plan for communication, like a daily telephone contact or video talk. This method, you can be sure to include quality time together.

Be polite of your partner’s requires and lifestyle, including pastimes and friends. Do n’t try to make them feel bad about their interests or try to change them. Respect that and put your energy into other things in your life until the right moment is right for you to merge your two worlds if you ca n’t be together right now. In the meantime, this will help you remain stable and healthy.

5. Stay connected

In a long distance relationship, you need to be committed to each other. This entails being sincere with one another on every level, including being trustworthy. Nothing worsens a trustworthy and caring relation more quickly than lying.

Make it a habit to text or call one another frequently throughout the day. This keeps you both related and gives you anything to look forward to each day, even if it’s just for a quick chat.

Talk about your daily life, for as function, friends and family. This fosters a sense of shared existence and reduces psychological mileage. Additionally, it gives you more topics to discuss when you two re-connect. Besides, it ’s a great way to find more in-depth meetings than just chatting.