subjective information B. objective information C. an assessment D. a diagnosis 2. In a hospital setting‚ the care provider takes the patient ’s history‚ details the reason the patient is being admitted and performs a physical exam. The report of this information is known as the: A. initial progress note B. discharge summary C. history and physical D. SOAP note 3. The SOAP documentation format is most commonly used in which healthcare setting? A. hospital inpatient B. physician
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PHYSICAL EXAMINATION AND REVIEW OF SYSTEM Date: September 19‚ 2011 Name: Mr. Ironman Diagnosis: T/C Cerebrovascular Disorder‚ Hpn II Vital Signs Temperature: 36.7o C Height: 5’6” Pulse: 62 bpm Weight:170 lbs. ( 77.27) Respiration: 22 cpm Observation: Received patient lying on bed‚ lethargic‚ oriented to person‚ place‚ Blood Pressure:160/110 mmHg and time‚ with #1 PNSS 1L regulated @ KVO rate‚hooked @ Left hand‚ with 950
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Health History Virginia G Parrott Fort Hays State University Health History Health history assessment conducted on George on the fifteen of February 2010 at approximately one o’clock. George is a fifty-four year white male married with three adult children and two grand children. He has been working as a teacher for over twenty years a local middle school. This paper will highlight George’s health care issues and will identify five nursing diagnosis for him. Methods of Health History Interview
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Geriatric History and Physical with Problem List and Plan California State University‚ Dominguez Hills School of Nursing Health Assessment Lab BSN 381L General Patient Information Client: 81-year-old Caucasian/Italian female Source: Client‚ seems reliable Marital status: Widower Religion: Catholic Occupation: House wife Formal education: High school Primary language: English‚ written and spoken Secondary: None Reason for Seeking Care: Shortness of breath
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History and Examination of the Reproductive System Female reproductive history: - Age‚ gravidity (no. of pregnancies‚ including miscarriages/ectopics/stillbirths)‚ parity (no. of livebirths)‚ LMP (last menstrual period) - History of presenting complaints: o Nature and duration o Relation to menstrual cycle o Vaginal discharge o Vaginal bleeding o Urinary symptoms (dysuria‚ frequency‚ urge/stress incontinence) o Bowel symptoms - Previous gynaecological history: o Periods – regular
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PREFACE To provide a meaningful background of physical education and sport in modern society it is helpful to have a clear understanding of its role in the past and how it emerged. The purpose of this assignment is to outline the history of physical education since time immemorial. The text begins with the beginning of the humankind engaging in physical activities‚ showing the history of physical education and sport being a rich tapestry of people‚ places‚ events and social forces from early civilization
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Brief History of Physical Education A brief history of physical education in the United States would kick off in the nineteenth century. There was growing popularity of formal physical education programs all across Europe where calisthenics and gymnastics were all the rage. American schools looked to follow the European model by incorporating physical education into the curriculum for primary and secondary schools. And a brief history of physical education would not be complete with a consideration
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HISTORY AND PHYSICAL EXAMINATION Patient Name: Fanny Copeland Patient ID: 115463 DOB: 10/26/- - - - Age: 58 Sex: Female Room No.: Hillcrest Memory Diagnostic Center Date of Admission/Date of Arrival: 04/26/- - - - Referring Physician: Lyndon F. Talcott‚ MD‚ Neurology Admitting Diagnosis: Memory loss. BACKGROUND: Ms. Copeland is a 58-year-old left handed white female who was referred to the Hillcrest memory Diagnostic Center by the emergency room physician for evaluation
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HISTORY AND PHYSICAL EXAMINATION Patient Name: Adela Torres Patient ID: 132463 Room No.: 541 Date of Admission: 06/22/---- Admitting Physician: Leon Medina‚ MD‚ Internal Medicine Admitting Diagnosis: Stomatitis‚ possibly methotrexate related. Chief Complaint: Swelling of lips causing difficulty swallowing. HISTORY OF PRESENT ILLNESS: This patient is a 57-year-old Cuban woman with a long history of rheumatoid arthritis. She has received methotrexate on a weekly basis
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Karen Resotko September 10‚ 2013 History & Physical Cardiology He is a 47-year-old male who states that he has had a 7-year history of palpitations‚ which he describes as skipped‚ or fast beats. He states that the trigger is unclear. They can either last a few seconds‚ or several days‚ but he states also that he has had no rapid beating for sustained durations. He states that he also can get several episodes per month. He states also that he had an echo done seven years ago‚ when these symptoms
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