Reference no: EM132276362

Assignment - Case Study Directions ANP 669:

You will now produce a H&P detailing your next steps. Based upon your diagnosis and differential diagnosis formulate a SOAP note based on the case presented (fever or pain). Utilize all patient information in the appropriate area of the SOAP note. In ANP 669 in the Practicum Overview refer to the H&P folder for resources to support your H&P production.

This H&P should be no more than 1 page. You do not have to double space as APA is only requested in documentation of your plan where you will be required to produce the rationale for all elements of your plan based on evidence-based practices with in text citations and references within the last 5yrs. all peer-reviewed.

EXAM: For your physical exam portion, you will detail normal findings for this patient unless there are reported findings in the case study to report as negative findings. Always document CV, Pulmonary and GI exam. No video for this exam. Only documentation required.

ECG: Address question below the ECG in your plan. Include ECG findings in the necessary section of your SOAP.

Genogram - Complete a three generation Genogram based on the information provided in this case study.

Immunization History: Include the proposed immunizations this patient should have to be up to date at the age 21 years old. Also detail future immunization plan for this patient into Geriatrics (age 65).

Case Study -

A 21-year-old woman college student complains of fatigue, an unintentional 10-lb weight loss, and a persistent oral ulcer and bleeding gums. On physical examination, swelling and tenderness of the distal joints in both hands are also noted. Patient also with complaints of facial flushing with red spots on her cheeks. She has unchanged appetite despite weight loss, no nausea, emesis, or diarrhea. She also does not report visual disturbances, denies shortness of breath, and cough. She has skin changes with rashes most notable to face, but also throughout legs and arms. She indicates her mother has a medical history of HTN, CAD, and Rheumatoid arthritis. Her father has history of HTN, Vasculitis, and ESRD s/p Renal transplant at the age of 28. Her siblings, one brother has medical hx of HTN, and three sisters all of which have rheumatoid arthritis, HTN, and psoriasis. Her maternal grandmother has medical history of DM, CAD, HLD, and cutaneous lupus erythematosus. The patients maternal grandfather is deceased due to a AMI at the age of 55. Her paternal grandmother with history of breast cancer, hypothyroidism, and COPD. The patients paternal grandfather with history of CHF, COPD, and s/p AAA repair at age 72.

She is currently taking multi-vitamins, birth control (Loloesterine FE), and Hydralazine. She works out 1-2 times per week, sexually active, denies ETOH and illicit. This is her ECG below (attached).

This ECG is ECG obtained on both patients based on the basic ECG interpretation:

1. What is the rate, and rhythm?

2. If follow up is needed, address follow up in SOAP plan for 669?

Genogram -

A genogram is a graphic representation of a family tree that displays detailed data on relationships among individuals. It goes beyond a traditional family tree by allowing the user to analyze hereditary patterns and medical diagnosis that punctuate relationships. Genograms allow an APN to identify and understand various patterns in the patient's family history which may influence the patient's current health. The genogram maps out relationships and traits that may otherwise be missed on a pedigree chart. To create a medical genogram, you must first determine which genetic diseases you wish to include.

Due to HIPPA, you are to develop a genogram covering three generations based on information from Case study to reveal the illustration of a family medical diagnosis and relationships. The genogram can be produced as a word document using shapes, figures, and directional illustrations. Make genogram complete with a legend identifying figures. Include family order, and diagnosis required. Feel free to be creative. To be completed in accordance with Case study.

Attachment:- Assignment Files.rar