Unit 7 soap

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 see attached

Name:  Anna Jones

 Pt. Encounter Number: 5663

Date: 9/13/22

Age: 54

Sex: Female

SUBJECTIVE

CC: 

“low back pain radiating to left leg”

 

HPI: 

54 yo female presents to the office today c/o lower back pain radiating down L buttock, down the left leg through the calf. Began 3 days ago, with sudden onset while she was at work, following lifting and turning a patient.. She reports feeling a “pop” followed immediately by this pain. States the pain is constant and worsening and rates severity as 7/10. Describes the pain as throbbing, with stinging and tingling down the left leg and calf and reports she “feels crooked”. She has tried rest and Ibuprofen to treat the pain but has gotten no relief. She reports sitting worsens the pain and she is unable to walk without pain. Denies history of similar symptoms. No recent trauma. No previous treatment or testing related to this problem.

Medications:
Ibuprofen 400mg as needed for back pain

 

Allergies:
NKDA

 

Medication Intolerances:
none reported

Past Medical History:
Uterine fibroids

 

Chronic Illnesses/Major traumas:
denies

 

Hospitalizations/Surgeries:
3 live births, partial hysterectomy due to uterine fibroids

Preventive
: Immunizations up to date .Tdap 2015, Flu 2019, COVID #1 Jan 2020, COVID#2 Feb 2020. Yearly dental exam. Mammogram March 2020.

 

Family History

Mother deceased due to COVID with history of asthma and smoking. Father living, age 86, HTN-controlled, smoker, depression.

 

Social History

Pt attended tech school and is working full time as a nursing assistant. Married and monogamous with husband. She has 3 children. Owns home and feels safe there. Denies smoking, tobacco or recreational drug use. Reports occasional use of wine.

 

ROS Student to ask each of these questions to the patient: “Have you had any…..”

General

Denies weight change, fatigue, fever, chills, night sweats, or change in energy level

 

Cardiovascular

Denies chest pain, palpitations, edema.  

Skin

Denies rashes, bruises or bleeding, or change in skin lesions.  

Respiratory

Denies cough, SOB. 

Eyes

Denies visual changes

 

Gastrointestinal

Denies abdominal pain, N/V/D, constipation, eating disorders or ulcer

 

Ears

Denies ear pain or hearing loss.

 

Genitourinary/Gynecological

Denies dysuria or incontinence. Reports last PAP 2010, normal. 3 live births.

 

Nose/Mouth/Throat

Denies congestion or sinus problems. Denies nosebleed. Denies dental disease. Denies sore throat or hoarseness

 

Musculoskeletal

Reports throbbing lower back pain, radiates to Left buttock and down to left leg/calf for 3 days. Worsening and causing pain when ambulating. Not relieved by rest, position change or Ibuprofen. Denies history of similar problems. Denies joint swelling or history of arthritis.

Breast

Reports regular SBE, Denies lumps or mass. Last mammogram March 2020

Neurological

Alert and oriented x 4. Denies syncope, seizures. Reports stinging and tingling down left calf but denies numbness.

Heme/Lymph/Endo

Denies swollen or painful nodes, denies temperature intolerance, night sweats .

Psychiatric

Denies depression. Reports anxiety and feeling overwhelmed, but no previous evaluation or treatment. States she self-medicates with exercise or occasional wine.

OBJECTIVE

Weight     110lbs   BMI 17.8

Temp 98.3

BP 115/80 left, 116/82 right

Height 5’6’’

Pulse 76

Resp 24
O2 sat 99%

General Appearance

Healthy-appearing adult female in no acute distress.

Skin

Skin warm, dry, clean, and intact. No rashes or lesions noted.

HEENT

Head is normocephalic, atraumatic.. Eyes:  PERRLA. EOMs intact. No conjunctival or scleral injection. Ears: Canals patent. Bilateral TM pearly gray, no bulging. Nose: Nasal mucosa pink; normal turbinates. Neck: Supple. Full ROM. No lymphadenopathy. Oral mucosa, pink and moist. Teeth are in good repair.

Cardiovascular

S1, S2 with regular rate and rhythm. No clicks, rubs, or murmurs. Capillary refills two seconds. Pulses 3+ throughout. No edema.

Respiratory

Symmetric chest wall. Respirations regular and easy; lungs clear to auscultation bilaterally.

Gastrointestinal

BS active in all the four quadrants. Abdomen soft, nontender. No hepatosplenomegaly

Breast

Deferred.

Genitourinary

No CVA tenderness. No incontinence during visit.

Musculoskeletal

Reduced forward flexion of lumbar spine. Left straight leg raise limited to 45 degrees. Left leg sciatic stretch test positive. Reduced response to light touch and pin prick lateral and dorsal left calf. Grade 4 weakness on dorsiflexion of left foot. Reduced right ankle jerk reflex. Negative reversed straight leg raise. Normal curvature of cervical, thoracic and lumbar spine. Gait slow and guarded. Spinal processes nontender. On standing, left shoulder appears higher than right. Full ROM of upper extremities.

Neurological

Oriented x 4 and answers questions appropriately. Speech clear.

Psychiatric

Maintains eye contact. Speech is of normal rate and cadence. Normal mood and affect.

Lab Tests/Imaging

MRI-
normal

Xray-
normal

 

Assessment

· Include at least three differential diagnoses-acute low back pain, sciatica, herniated disc

· Provide rationale for each differential diagnosis

· Final diagnosis -Acute low back pain, sciatica

· Pathophysiology of primary and rationale for choosing as final

Plan

· Medications

· Non-pharmacological recommendations

· Diagnostic tests

· Patient education

· Culture considerations

· Health promotion

· Referrals

· Follow up

Rubric Title: Unit 2, 4, 6 Lab – Virtual Reality Rubric

***Students: It is IMPORTANT to remember to utilize both the “Guided Mode” and “Expert Mode” in the VR Lab Simulation case scenario experiences, as you practice the VR Lab scenario(s). The “Guided Mode” and “Expert Mode” allow you to have multiple tries/attempts to practice the case. THEN, when you feel you are ready, you will choose the VR Lab “Exam Mode” (that you can ONLY attempt once); the score you receive in “Exam Mode” will then be your final grade in the VR Lab. If you have any questions regarding this, please follow up with your course instructor.


Assignment Criteria


Level III

Level II

Level I

Not Present

Criteria 1

Level III

Points: 80

Level II

Points: 64

Level I

Points: 48

Not Present

0 Points

Total Score

· Within Exam Mode, obtains 65 to 80 points of the required total components for virtual reality patient scenario

· Within Exam Mode, obtains between 49 to 64.9 points of the required total components for virtual reality patient scenario

· Within Exam Mode, obtains between 33 to 48.9 points of the required total components for virtual reality patient scenario

· Does not attempt in Exam Mode

· Does not meet the criteria

Rubric Title: Unit 3, 5, 7 SOAP Journal Assignment Rubric

Criteria 1

Level III Max Points

Points: 8

Level II Max Points

Points: 6.4

Level I Max Points

Points: 4.8

0 Points

Content Quality- Subjective Data

Subjective data displays complete understanding of all critical concepts of virtual reality patient case including:

· Name, age, gender

· Chief complaint

· History of present illness (HPI) that follows OLD CARTS pneumonic

· Medications

· Allergies

· Past medical history

· Past surgical history

· Pertinent family history

· Social history

· Review of Systems

· Subjective data displays understanding of critical concepts of chosen virtual reality patient case; there may be 1-2 critical concepts with errors/omissions or lack of details.

· Subjective data displays understanding of critical concepts of chosen virtual reality patient case; there may be 3-4 critical concepts with errors/omissions or lack of details.

· Does not meet criteria

Criteria 2

Level III Max Points

Points: 8

Level II Max Points

Points: 6.4

Level I Max Points

Points: 4.8

Not Present

0 Points

Content Quality- Objective Data

Objective data displays complete understanding of all critical concepts of chosen virtual reality patient case including:

· Vital signs

· Body systems that are pertinent to specific case

· Objective data displays understanding of critical concepts of chosen virtual reality patient case; there may be 1-2 critical concepts with errors/omissions or lack of details.

· Objective data displays understanding of critical concepts of chosen virtual reality patient case; there may be 3-4 critical concepts with errors/omissions or lack of details

· Does not meet criteria

Criteria 3

Level III Max Points

Points: 4

Level II Max Points

Points: 3.2

Level I Max Points

Points: 2.4

Not Present

0 Points

Content Quality- Assessment

Assessment displays complete understanding of all critical concepts of chosen virtual reality patient case including:

· Primary diagnosis

· Pathophysiology of primary diagnosis

· Three differential diagnoses

· Rationales for differential diagnoses

· Assessment displays understanding of critical concepts of chosen virtual reality patient case; there may be 1 critical concept with errors/omissions or lack of details.

· Assessment displays understanding of critical concepts of chosen virtual reality patient case; there may be 2 critical concepts with errors/omissions or lack of details.

· Does not meet criteria

Criteria 4

Level III Max Points

Points: 4

Level II Max Points

Points: 3.2

Level I Max Points

Points: 2.4

Not Present

0 Points

Content Quality- Plan of Care

Plan displays complete understanding of all critical concepts of chosen virtual reality patient case including:

· Medications

· Non-pharmacological recommendations

· Diagnostic tests

· Patient education

· Cultural considerations

· Health promotion

· Referrals

· Follow-Up

· Plan displays understanding of critical concepts of chosen virtual reality patient case; there may be 1 critical concept with errors/omissions or lack of details.

· Plan displays understanding of critical concepts of chosen virtual reality patient case; there may be 3-4 critical concepts with errors/omissions or lack of details.

· Does not meet criteria

Criteria 5

Level III Max Points

Points: 3

Level II Max Points

Points: 2.4

Level I Max Points

Points: 1.8

Not Present

0 Points

Collegiate-level academic writing

· Includes no more than three grammatical, spelling, or punctuation errors that do not interfere with the readability.

· Supports all opinions and ideas with relevant and credible reference sources of information.

· Provides three or more peer-reviewed or evidence-based practice scholarly references sources.

· All reference sources are within the past five years.

· Includes no more than four grammatical, spelling, or punctuation errors that do not interfere with the readability.

· Supports many opinions and ideas with relevant and credible sources of information.

· Provides two peer-reviewed or evidence-based practice scholarly references sources.

· All reference sources are within the past five years.

· Includes five or more grammatical, spelling, and punctuation errors that makes understanding parts of assignment difficult, but does not interfere with readability.

· Not all references utilized are relevant and/or credible sources of information.

· Provides one peer-reviewed or evidence-based practice scholarly references source.

· Reference sources are within the past five years.

· Does not meet criteria

Criteria 6

Level III Max Points

Points: 3

Level II Max Points

Points: 2.4

Level I Max Points

Points: 1.8

0 Points

Citations and Formatting

● The overall order of information is clear and contributes to the meaning of the assignment. There may be 1-2 sentences, or one paragraph that is out of order, or other minor organization issues.

● Correctly citing all reference sources. One or two formatting, in-text, or reference citation errors may occur.

● Quotation marks and citations make authorship clear.

● The overall order of information is confusing in places due to 3-4 sentences, or two paragraphs that may be out of order, or other organization issues that interfere with the meaning or intent of the paper.

● Correctly citing all reference sources. 3-4 formatting, in-text, or reference citation errors may occur.

● Quotation marks and citations generally, make authorship clear.

● The overall order of information is confusing in places due to 5-6 sentences or three paragraphs that may be out of place, or other organization issues that interfere with the meaning or intent of the paper.

● Attempts to cite. 5-6 formatting, in-text, or reference citation errors may occur.

● Quotation marks and citations may be missing or incorrect.

● Authorship may be unclear in areas.

· Does not meet criteria

Maximum Total Points

30

24

18

Minimum Total Points

25

19

Rubric Title: Unit 8 Journal Rubric

Criteria 1

Level III Max Points

Points: 15

Level II Max Points

Points: 12

Level I Max Points

Points:9

0 Points

Content Quality- Subjective Data

Presentation of subjective data displays complete understanding of all critical concepts of chosen virtual reality patient case including:

· Name, age, gender

· Chief complaint

· History of present illness (HPI) that follows OLD CARTS pneumonic

· Medications

· Allergies

· Past medical history

· Past surgical history

· Pertinent family history

· Social history

· Review of Systems

· Presentation of subjective data displays understanding of all critical concepts of chosen virtual reality patient case; there may be 1-2 critical concepts with errors/omissions or lack of details.

· Presentation of subjective data displays understanding of all critical concepts of chosen virtual reality patient case; there may be 3-4 critical concepts with errors/omissions or lack of details.

· Does not meet the criteria

Criteria 2

Level III Max Points

Points: 15

Level II Max Points

Points: 12

Level I Max Points

Points:9

0 Points

Content Quality- Objective Data

Presentation of objective data displays complete understanding of all critical concepts of chosen virtual reality patient case including:

· Vital signs

· Body systems that are pertinent to specific case

· Presentation of objective data displays understanding of all critical concepts of chosen virtual reality patient case; there may be 1-2 critical concepts with errors/omissions or lack of details.

· Presentation of objective data displays understanding of all critical concepts of chosen virtual reality patient case; there may be 3-4 critical concepts with errors/omissions or lack of details.

· Does not meet the criteria

Criteria 3

Level III Max Points

Points: 15

Level II Max Points

Points: 12

Level I Max Points

Points:9

0 Points

Content Quality- Assessment

Presentation of assessment displays complete understanding of all critical concepts of chosen virtual reality patient case including:

· Primary diagnosis

· Pathophysiology of primary diagnosis

· Three differential diagnoses

· Rationales for differential diagnoses

· Presentation of assessment displays understanding of all critical concepts of chosen virtual reality patient case; there may be one critical concept with errors/omissions or lack of details.

· Presentation of assessment displays understanding of all critical concepts of chosen virtual reality patient case; there may be two critical concepts with errors/omissions or lack of details.

· Does not meet the criteria

Criteria 4

Level III Max Points

Points: 15

Level II Max Points

Points: 12

Level I Max Points

Points:9

0 Points

Content Quality- Plan of Care

Presentation of plan displays complete understanding of all critical concepts of chosen virtual reality patient case including:

· Medications

· Non-pharmacological management

· Diagnostic tests

· Patient education

· Cultural considerations

· Health promotion

· Referrals

· Follow-Up

· Presentation of plan displays understanding of all critical concepts of chosen virtual reality patient case; there may be one critical concept with errors/omissions or lack of details.

· Presentation of plan displays understanding of all critical concepts of chosen virtual reality patient case; there may be 3-4 critical concepts with errors/omissions or lack of details.s

· Does not meet the criteria

Criteria 5

Level III Max Points

Points: 15

Level II Max Points

Points: 12

Level I Max Points

Points:9

0 Points

Quality of Oral Presentation

· Presentation demonstrated thorough organization and delivery.

· All ideas were stated in a clear and logical manner.

· Presentation was on topic and relevant.

· Presentation time no longer than 5 minutes

· Presentation was organized and well spoken.

· All ideas were stated in a clear and logical manner.

· Presentation was on topic and relevant.

· Presentation >5 minutes

· Presentation needed more details or content inconclusive.

· Presentation >5 minutes

· Does not meet the criteria

Maximum Total Points

75

60

45

0

Minimum Total Points

61

46

1

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