Make a SOAP Note Not a narrative essay: Ankle Pain

Note:  Your Discussion post should be in the SOAP Note format, rather than the traditional narrative style Discussion posting format. Refer to the Comprehensive SOAP Template in the attachments below for guidance.  

CASE: Ankle Pain

A 46-year-old female reports pain in both of her ankles, but she is more concerned about her right ankle. She was playing soccer over the weekend and heard a “pop.” She is able to bear weight, but it is uncomfortable. In determining the cause of the ankle pain, based on your knowledge of anatomy, what foot structures are likely involved? What other symptoms need to be explored? What are your differential diagnoses for ankle pain? What physical examination will you perform? What special maneuvers will you perform? Should you apply the Ottowa ankle rules to determine if you need additional testing?

To prepare:

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.

Address all these in the SOAP Note not an Narrative Essay (Follow the SOAP Note Template on the attachment):

1.     A description of the health history you would need to collect from the patient in the case study to which you were assigned.

2.     Explain what physical exams and diagnostic tests would be appropriate and how the results would be used to make a diagnosis.

3.     List  five  different possible conditions for the patient’s differential diagnosis, and justify why you selected each.

4.     Include how the patient X-ray (in the attachment below)  helped you to refine the differential diagnosis

5. Please address also all the questions on the case above in the SOAP note.

REMINDER: Please make a SOAP NOTE for this case. Make your own patient’s data, applicable health history, review of systems, P.E., labs, differential diagnosis, final diagnosis etc. Incorporate the data from the case in the SOAP note that you will do… This is not a narrative essay ok…. I need SOAP note (Nurse Practitioner/RN/MD  makes SOAP note)… Be guided with the SOAP Note in the templates/exemplar… Don’t copy paste. Formulate your own… Don’t forget to cite the Five different possible conditions (Differential diagnosis) and have Reference lists too.

Resources:

·         Ball, J. W., Dains, J. E., Flynn, J. A., Solomon, B. S., & Stewart, R. W. (2015).  Seidel’s guide to physical examination  (8th ed.). St. Louis, MO: Elsevier Mosby.

o    Review of Chapter 4, “Vital Signs and Pain Assessment” (pp. 50-63)

o    Chapter 21, “Musculoskeletal System” (pp. 501-543)

This chapter describes the process of assessing the musculoskeletal system. In addition, the authors explore the anatomy and physiology of the musculoskeletal system.

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

o    Chapter 22, “Limb Pain” (pp. 356-374)

This chapter outlines how to take a focused history and perform a physical exam to determine the cause of limb pain. It includes a discussion of the most common tests used to assess musculoskeletal disorders.

o    Chapter 24, “Low Back Pain (Acute)” (pp. 288-300)

The focus of this chapter is the identification of the causes of lower back pain. It includes suggested physical exams and potential diagnoses.

   Sullivan, D. D. (2012).  Guide to clinical documentation  (2nd ed.). Philadelphia, PA: F. A. Davis.

o    Chapter 2, “The Comprehensive History and Physical Exam” (“Muscle Strength Grading”; p. 26)

o    Chapter 4, “Pediatric Preventative Care Visits” (“Documentation of Important Components of Age Specific Physical Exams and Sports Pediatric Sports Participation Physical Exam”; pp. 78–79)

Note:  Download this Adult Examination Checklist and Physical Exam Summary: Abdomen to use during your practice musculoskeletal examination.

   Seidel, H. M., Ball, J. W., Dains, J. E., Flynn, J. A., Solomon, B. S., & Stewart, R. W. (2011).  Adult examination checklist: Guide for musculoskeletal assessment . In  Mosby’s guide to physical examination  (7th ed.). St. Louis, MO: Elsevier Mosby.
This Adult Examination Checklist: Guide for Musculoskeletal Assessment was published as a companion to Seidel’s guide to physical examination (8th ed.), by Ball, J. W., Dains, J. E., & Flynn, J. A. Copyright Elsevier (2015). From https://evolve.elsevier.com/

   Seidel, H. M., Ball, J. W., Dains, J. E., Flynn, J. A., Solomon, B. S., & Stewart, R. W. (2011).  Physical exam summary: Musculoskeletal system . In  Mosby’s guide to physical examination  (7th ed.). St. Louis, MO: Elsevier Mosby.
This Musculoskeletal System Physical Exam Summary was published as a companion to Seidel’s guide to physical examination(8th ed.), by Ball, J. W., Dains, J. E., & Flynn, J. A. Copyright Elsevier (2015). From https://evolve.elsevier.com/

   Katz, J. N., Lyons, N., Wolff, L. S., Silverman, J., Emrani, P., Holt, H. L., & …Losina, E. (2011). Medical decision-making among Hispanics and non-Hispanic Whites with chronic back and knee pain: A qualitative study.  BMC Musculoskeletal Disorders ,  12 (1), 78–85.
Retrieved from the Walden Library databases.

This study examines the medical decision making among Hispanics and non-Hispanic whites. The authors also analyze the preferred information sources used for making decisions in these populations.

   Vismara, L., Menegoni, F., Zaina, F., Galli, M., Negrini, S., & Capodaglio, P. (2010). Effect of obesity and low back pain on spinal mobility: A cross sectional study in women.  Journal of Neuroengineering & Rehabilitation ,  7 (1), 71–83.
Retrieved from the Walden Library databases.

In this study, the authors explore the effect of obesity and chronic low back pain on spinal mobility. The authors use range of motion as a metric of spinal mobility.

   University of Virginia. (n.d.).  Introduction to radiology: An online interactive tutorial . Retrieved from http://www.med-ed.virginia.edu/courses/rad/index.html
This website provides an introduction to radiology and imaging. For this week, focus on skeletal trauma in musculoskeletal radiology.

Media

Online media for  Seidel’s Guide to Physical Examination

In addition to this week’s resources, it is highly recommended that you access and view the resources included with the course text,  Seidel’s Guide to Physical Examination . Focus on the videos and animations in Chapter 21 that relate to the assessment of the musculoskeletal system. Refer to the Week 4 Learning Resources area for access instructions on   https://evolve.elsevier.com/ .

Optional Resources

·         LeBlond, R. F., Brown, D. D., & DeGowin, R. L. (2009).  DeGowin’s diagnostic examination  (9th ed.). New York, NY: McGraw Hill Medical.

o    Chapter 13, “The Spine, Pelvis, and Extremities” (pp. 585–682)

In this chapter, the authors explain the physiology of the spine, pelvis, and extremities. The chapter also describes how to examine the spine, pelvis, and extremities.

Prepare a 2-3 pages paper with a minimum of three credible citations with references.

Correctional Health Care Assignment

You applied and were accepted in an internship program of a state-level, Female Correctional Health Care Operation in the South Eastern United States and your primary responsibility is to work on the assigned projects related to the provision of inmate health care.

Associated materials: 

The Health and Health Care of US Prisoners: Results of a Nationwide Survey

Public Health Behind Bars

Sample Tool Control Policy

Inmate Sick Call Procedures-Corrections

For the incarcerated population in the United States, health care is a constitutionally guaranteed right under the provisions of the eight amendment which is the prohibition against cruel and unusual punishment (see Estelle v. Gamble). This particular prison can hold in excess of 1,728 offenders and routinely houses between 1,600 and 1,700 women on any given day. This institution incarcerates all custody classes to include minimum security, medium security, close custody, death row, and pretrial detainees. 

The health care operation provides the highest level of care for the female offender in the state. The health care facility is a 101 thousand square foot, 150 bed, three-story building that cost the taxpayers $50 million dollars to construct and is a hybrid of an ambulatory care center, long-term care center, and a behavioral care center. The health care facility also houses an assisted living dorm.

The patient demographic includes women who have multiple co-morbidities including substance abuse, seriously persistent mental illnesses (SPMI), diabetes, cardiovascular disease, cancer, morbid obesity, HIV / AIDs, hepatitis, etc. On any given day there will also be 30 to 60 offenders who are pregnant, with 98% of those offenders having a history of substance abuse; all pregnant offenders are considered high-risk. The dental health of this patient population is exceptionally horrendous because of excessive drug abuse coupled with a sugary diet and poor oral hygiene practices. It is not uncommon for a 23-year-old to need all of her teeth extracted.

There are approximately 300 FTEs to include correctional staff that operate the facility and provide care to the offender population. The healthcare facility is comprised of the following directorates: (a) Medical, (b) Nursing, (c) Behavioral Health, (d) Pharmacy, (e) Dental, (f) Medical Records, (g) Health Service Support, and (h) Operations and Security.

Although the health care facility has a vast amount of capability, there limitations: (a) This facility does not have advanced cardiac life support capability (ACLS), (b) no surgical capability, (c) no ability to conduct telemetry, (d) no oral surgery beyond simple extractions, (e) no obstetrical capability beyond out-patient clinics, (f) MRI, (g) level 2 ultrasound, and the list goes on.

Those inmates who have medical needs that cannot be addressed by the health services staff at the correctional facility will need appointments with external health care providers who have a business relationship with the prisons in this area. On any given month, there will be approximately 300 offenders who will go to outside medical appointments and making certain that these appointments take place this is where the challenge lies. Similar to many health care operations, the prison Utilization Review / Case Management Department facilitates all external appointments and form the lynchpin between the correctional facility health care providers who refer offenders for specialty appointments, and the outside organization providing that appointment.  

Your assignment: You are the Case Coordinator. You have 300 patients that need to be scheduled for outside specialty appointments every month. You are tasked by the Administrator to develop a strategic plan organizing the out of the facility appointments without impairing internal services.

Your Assignment:

 Prepare a table (freestyle) addressing the following:

1. Identify what information and evidence you have to apply to the strategic process steps.

2. Identify appropriate evidence you still need to correctly use the strategic planning process. (HINT: make sure to list all types of evidence you need)

3. Identify the sources of the needed evidence. Offer the stakeholders able to provide you with the evidence you are seeking.

Evidence Table Example

To Prepare for this Discussion: Review Chapter 11 of the McKenzie et al. text. Pay particular attention to marketing strategies. Review “Community Advocacy” on pages 212–215 in Chapter 8 of the McKenzie et al. text and consider the use of advocacy strategies for marketing your public health program. Create a marketing product for your public health program including a name, slogan, and any other unique aspects to promote your program. This could be a brochure, flyer, poster series, or some other marketing product. Think about marketing strategies you would use to promote your public health program.

With these thoughts in mind: By Day 4

Post the marketing product idea or proposal you developed to promote your public health program. Explain how this marketing product may reach your target audience and explain why it may be effective in communicating your public health program.

The goal of this discussion forum is to offer you an introduction to the field of cognitive psychology. Cognitive psychology is a discipline within psychology that is concerned with the scientific study of the human mind. The mind is responsible for a variety of functions and abilities, including perception, attention, consciousness, memory, reasoning, and decision-making. Most of our mental life is unconscious. If the objects of our attention are equated to the objects of our consciousness, it is reasonable to assume that we are aware of only a limited number of events in our daily lives.

For your initial post, complete the following steps: Watch the video entitled, The Magic of the Unconscious: Automatic Brain (Links to an external site.)Links to an external site.. Select a “hot topic” of cognitive psychology based on what you have heard and/or seen in the media and your personal interests. Look for a report in the media (e.g., newspapers, magazines, web pages of professional organizations, etc.) that refers to the selected topic such as “defendant cannot remember what happened,” “false memories explain UFO abduction stories,” and so forth. Describe the content of the selected report and offer your own perspective. Namely, use your critical-thinking skills to examine the extent to which the claims made in the report and the evidence upon which the report relies are to be trusted. Then, discuss the real-life consequences of the evidence reported.

In your post, include a link to the selected report, and explain to the members of the class why you have selected it. Support your points with evidence from at least one peer-reviewed research article. Your initial post must be a minimum of 300 words.

Reference:

https://fod.infobase.com/OnDemandEmbed.aspx?token=51893&wID=100753&plt=FOD&loid=0&w=560&h=315&fWidth=580&fHeight=365

The Future of Healthcare

Our text states, “The baby boomers have entered their 60’s and will continue to be the most powerful segment of consumers.” Predict how healthcare will continue to evolve over the next decade. How will this affect the role of the supervisor?

Please respond to the initial question by day 5 and be sure to post two additional times to peers and/or instructor by day 7. The initial post by day 5 should be a minimum of 150 words. If you use any source outside of your own thoughts, you should reference that source. Include solid grammar, punctuation, sentence structure, and spelling.

Dunn & Haimann’s Healthcare Management: Chapters 27-29