This assignment will demonstrate your ability to provide age-appropriate anticip

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This assignment will demonstrate your ability to provide age-appropriate anticip

This assignment will demonstrate your ability to provide age-appropriate anticipatory guidance while recognizing the need to refer patients that are outside of the scope of practice of the family nurse practitioner. This will be demonstrated by completing a SOAP note based on the virtual reality patient you evaluated in Unit 6.
VIRTUAL PATIENT UNIT 6 INFO:
Mr. Moses Sinclair, is a 68 year old male presenting with the complaint of right hand pain and weakness.
Vital Signs
BP 134/64
Pulse 75
Temp 37.6 °C
NO PAST MEDICAL HISTORY
PARENTS ARE HEALTHY
HAS GLASS OF WINE EVERY NIGHT
DOES NOT SMOKE
NO RECREATIONAL DRUG USE
HAS BEEN TAKING EXTRA STRENTH TYNENOL FOR THE RIGHT HAND PAIN
HAS NO PREVIOUS HOSPITALIZATIONS
HAS NO PREVIOUS SURGERIES
DOES NOT TAKE ANY PRESCRIPTION MEDS
ASSESSMENT PHYSICAL:
NO ISSUES WITH CIRCULATION, NO PERIPHERAL VASCULAR DISEASE
NO CARDIAC DISEASE
NO RESPIRATORY ISSUES
NO VISION ISSUES r
ROM SEEMS FINE ON ALL EXTREMITIES
MUSKULOSKELETAL ASSESSMENT: CERVICAL SPINE, PALPATION, CRANIAL NERVES
MANAGEMENT:
ORDER TREATMENTS: WRIST SPLINT BRACE
REFERAL TO ORTHOPEDICS (CARPEL TUNNEL)
FOLLOW UP AS NEEDED WITH PRIMARY
PLEASE PROVIDE 3 OR MORE REFERENCES FOR THE ANTICIPATORY GUIDANCE. DO NOT REFERENCE FROM MAYO CLINIC PLEASE. APA STYLE REFERENCES. THEREFORE THEY MUST BE CITED IN TEXT.
Write-ups
The SOAP note serves several purposes:
It is an important reference document that provides concise information about a patient’s history and exam findings at the time of patient visit.
It outlines a plan for addressing the issues which prompted the office visit. This information should be presented in a logical fashion that prominently features all of the data that’s immediately relevant to the patient’s condition.
It is a means of communicating information to all providers who are involved in the care of a particular patient.
It allows the NP student an opportunity to demonstrate their ability to accumulate historical and examination-based information, make use of their medical knowledge, and derive a logical plan of care.
Knowing what to include and what to leave out will be largely dependent on experience and your understanding of illness and pathophysiology. If, for example, you were unaware that chest pain is commonly associated with coronary artery disease, you would be unlikely to mention other coronary risk-factors when writing the history. As you gain experience, your write-ups will become increasingly focused. You can accelerate the process by actively seeking feedback about all the H&Ps that you create as well as by reading those written by more experienced practitioners.
The core aspects of the SOAP note are described in detail below.
For ease of learning, a SOAP Note Template (I WILL ATTACH TEMPLATE DOWN BELOW) has been provided. For this assignment, proper citation and referencing is required because this is an academic paper.
S: Subjective information. Everything the patient tells you. This includes several areas including the chief complaint (CC), the history of present illness (HPI), medical history, surgical history, family history, social history, medications, allergies, and other information gathered from the patient. A commonly used mnemonic to explore the core elements of the history of present illness (HPI) is OLD CARTS, which includes: Onset, Location, Duration, Characteristics, Aggravating factors, Relieving factors, Treatments, and Severity.
O: Objective is what you see, hear, feel or smell. Your physical exam including vital signs.
A: Assessment/Your differentials
P: Plan of care including health promotion and disease prevention for the patient related to their age and gender.

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