Nursing

Lower Back Pain Low back muscle strain related to lifting Plan Refer to physical therapy Review body mechanics Advil prn as needed, Discuss exercise and weight bearing exercises Return to clinic if symptoms worsen Provide Ms. Jones with materials detailing stretching techniques the lower back. • Initiate treatment with ibuprofen 600 mg by mo every […]

Subjective Data Collection Objective Data Collection Education & Empathy Documentation Document: Provider Notes   Student Documentation Model Documentation Objective HENT: WNL No abnormalities found Upper extremiteis: WNL: no abnormality found: ROM: wnl Spine: reduced ROM for extension and flexion and lateral bending Hips: ROM wnl Lower extremity: Root foot with scar: healed well . Strength

Musculoskeletal Results | Turned In Advanced Physical Assessment – March 2020, advanced_physical_assessment__td8__031720__sect1 Return to Assignment (/assignments/313477/) Documentation / Electronic Health Record Document: Provider Notes Student Documentation Model Documentation Subjective This is a 28 yo pleasant african american female. She is the primary source of history and offers information freely. she speaks clearly and coherent and

Objective:Student Documentation Model Documentation   Oriented to person, place and time. Judgement and knowledge intact: Memory intact. no slurred speech Head: symmetrical no lesions, no trauma Weber test intact, rinne test intact, facial sensation intact, gag reflex intact Eyes: Blurry vision with prolong reading: Right eye vision 20/40: retina: with glacoma cupping. Left eye vision

Transcript:Student Documentation Model Documentation Subjective Data Collection Objective Data Collection Education & Empathy Documentation Document: Vitals Document: Provider Notes   Student Documentation Model Documentation Assessment Differential diagnosis: 1. flu-like syndrome or cold 2. strep throat 3. Allergies 4. Allergic rhinitis My differentials include cold, strep throat, rhinitis, allergies and asthma based on abnormal findings affecting

Your Results Lab Pass Objective Daniel appears slightly tired, and has been coughing throughout the exam Vital signs stable Spirometer: FEV1: 3.15L FVC 3.91L/ 80.5% Head: Cervical lymph nodes enlarged and tender on right side; Sinus: no tenderness on frontal or maxillary eyes: pink in color, no discharge Ears: right ear redness and inflammed: no

Student Documentation Model Documentation Focused Exam: Cough Results | Turned In Advanced Physical Assessment – March 2020, advanced_physical_assessment__td8__031720__sect1 Return to Assignment (/assignments/313480/) Documentation / Electronic Health Record Document: Provider Notes Student Documentation Model Documentation Subjective Dany is a 8 year old hispanic boy, brought into clinic by his grandmother. He is able to answer the

Constipation causing abdominal mass Intestinal obstruction Diverticulitis Irritable bowel syndrome Mrs. Park’s bowel sounds are normoactive in all quadrants, with bruits or friction sounds. Scattered dullness in LLQ during percussion is suggestive of feces in the colon; otherwise, her abdomen is tympanic. Her abdomen is soft to palpation; mild guarding and oblong mass suggesting feces

  Document: Vitals Document: Provider Notes Student Documentation Model Documentation Objective Alert and oriented x3: Some discomfort due to abdominal pain HEENT: moist mucus mambrane, normal skin turgor, no tenting Heart: S1 and S2 with no abnormal heart sounds Lungs; CTA Liver: 1cm below Rt costal margin: nontender Abdomen: BS present at all quads, normoactive,

Focused Exam: Abdominal Pain Results | Turned In Advanced Physical Assessment – March 2020, advanced_physical_assessment__td8__031720__sect1 Return to Assignment (/assignments/313482/) Documentation / Electronic Health Record Document: Provider Notes Student Documentation Model Documentation Subjective Miss Park is a pleasant Korean 78 year old woman who presents to the clinic with complaints of abdominal pain for the past