USC Health & Medical Common Respiratory Diagnosis Paper Nursing Assignment Help

Debra, a 56-year-old female, comes to the clinic complaining of a cold she has had for several weeks that just will not go away. She states she has a dry hacking cough, muscle aches, and a headache. While it is very hot outside, she is shivering with a sweater on. She has tried many over-the-counter medications with no effect. She looks ill and is very fatigued. On chest auscultation, she has some inspiratory crackles and diminished breath sounds. You note some dullness on percussion over her left lower lobe. Her temperature is 100.5°.

Template

Case Study Chosen: (List what case you have chosen)

Demographics: Age/Gender

SUBJECTIVE

  • CC:
  • HPI: (As listed from Case Study Information)
  • Subjective: (What questions will you ask? Must be listed by System, ONLY as it pertains to Chief Complaint/HPI. Should NOT be all systems or full head to toe unless pertinent).

OBJECTIVE

General:

  • VS BP, HR, RR, Weight, Height, BMI
  • Physical Exam Elements: (Must be listed by System, ONLY as it pertains to Chief Complaint/HPI. Should NOT be all systems or full head to toe unless pertinent.)
  • POC Testing (any Point of Care (POC) testing specifically performed in the office): What tests (if any) did you perform during the visit (urine dip, rapid strep, urine pregnancy test, Glucose finger-stick, etc.)? Leave blank if none.

ASSESSMENT

  • Working Diagnosis: (Must include ICD 10)
  • Differential Diagnosis:

PLAN

  • Diagnostic studies: If any, will be ordered (Labs, X-ray, CT, etc.). Only include if you will be ordering for your patient. Remember the importance of appropriate resource utilization. Remember you are managing this patient in the CLINIC setting, NOT THE HOSPITAL.
  • Treatment: Must include full Sig/Order for all prescriptions and OTC meds (Name of medication, dosage, frequency, duration, number of tabs, number of refills). CANNOT only list drug class. Should follow evidence-based guidelines.
  • Referrals: If Applicable
  • Education:
  • Health maintenance:
  • RTC:

Table 1. Common Respiratory Diagnoses. If you completed your SOAP note on a Respiratory Prompt, you must also complete the following table.

Diagnosis

Signs/Symptoms

Gold Standard Diagnostics

Gold Standard Treatment

COPD

Community Acquired Pneumonia

Atypical Pneumonia

Acute Bronchitis

Asthma

Tuberculosis

Pulmonary Emboli

COVID-19

Upper Respiratory Infection

Influenza

Share This Post

Email
WhatsApp
Facebook
Twitter
LinkedIn
Pinterest
Reddit

Order a Similar Paper and get 15% Discount on your First Order

Related Questions

Aubre R. presents as a new patient to your practice having Nursing Assignment Help

Aubre R. presents as a new patient to your practice having recently relocated from rural Tennessee. She is 68 years old and complains of irritable bowel syndrome (IBS) with abdominal cramping and frequent diarrhea with occasional constipation. She has a history of domestic violence with resultant anxiety requiring inpatient hospitalization

Aubre R. presents as a new patient to your practice having Nursing Assignment Help

Aubre R. presents as a new patient to your practice having recently relocated from rural Tennessee. She is 68 years old and complains of irritable bowel syndrome (IBS) with abdominal cramping and frequent diarrhea with occasional constipation. She has a history of domestic violence with resultant anxiety requiring inpatient hospitalization

Walden University, LLC. (Producer). (2019b). Alzheimer’s Nursing Assignment Help

To Prepare  Review the interactive media piece for Alzheimer’s Disease.  (76 Year Old Iranian Male) Reflect on the patient’s symptoms and aspects of the disorder presented in the interactive media piece. Consider how you might assess and treat patients presenting with the symptoms of the patient case study you were assigned. You

To Prepare Review the interactive media piece for Nursing Assignment Help

To Prepare  Review the interactive media piece for Alzheimer’s Disease.  (76 Year Old Iranian Male) Reflect on the patient’s symptoms and aspects of the disorder presented in the interactive media piece. Consider how you might assess and treat patients presenting with the symptoms of the patient case study you were assigned. You

Students are required to maintain weekly reflective Nursing Assignment Help

Students are required to maintain weekly reflective narratives throughout the course to combine into one course-long reflective journal that integrates leadership and inquiry into current practice as it applies to the Professional Capstone and Practicum course. In your journal, you will reflect on the personal knowledge and skills gained throughout

Please respond to one discussion post. Compare your Nursing Assignment Help

Please respond to one discussion post. Compare your experience with the Active Verbs activity with that of your peer. Was their experience with the activity similar to yours? If they had similar experiences with the questions, discuss why you think you had similar outcomes. If they had different experiences with

1. Read: Discussion Background This week you are learning Nursing Assignment Help

1. Read: Discussion Background  This week you are learning about codes for services and procedures assigned from the Medicine Section. As you work on assigning codes for services performed from the Medicine Section, reflect on the purpose and meaning of the guidelines found throughout this section.  2. Initial Post: Create a new