Tag: Care Plans

[Solved] NUR 612 Clinical SOAP Note 1

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– a year ago **files (3)** – ## ASOAPnoteisamethodofdocumentationemployedbyhealthcareproviderstorecordandcommunicatepatientinformationinaclear.docx – ## SOAPNoteTemplate-1.docx – ## SoapNoterubric.docx **## ASOAPnoteisamethodofdocumentationemployedbyhealthcareproviderstorecordandcommunicatepatientin…

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Assignment Prompt & Instructions

– a year ago

**files (3)**

– ## ASOAPnoteisamethodofdocumentationemployedbyhealthcareproviderstorecordandcommunicatepatientinformationinaclear.docx

– ## SOAPNoteTemplate-1.docx

– ## SoapNoterubric.docx

**## ASOAPnoteisamethodofdocumentationemployedbyhealthcareproviderstorecordandcommunicatepatientinformationinaclear.docx**

A SOAP note is a method of documentation employed by healthcare providers to record and communicate patient information in a clear, structured, and in an organized manner. This assignment will provide students with the necessary tools to document patient care effectively, enhance their clinical skills, and prepare them for their roles as competent healthcare providers.

**Instructions:**

SOAP is an acronym that stands for Subjective, Objective, Assessment, and Plan. The episodic SOAP note is to be written using the attached template below.

For all the SOAP note assignments, you will write a SOAP note about one of your patients and use the following acronym:

| | |
| — | — |
| **S** = | Subjective data: Patient’s Chief Complaint (CC). |
| **O** = | Objective data: Including client behavior, physical assessment, vital signs, and meds. |
| **A** = | Assessment: Diagnosis of the patient's condition. Include differential diagnosis. |
| **P** = | Plan: Treatment, diagnostic testing, and follow up |

**## SOAPNoteTemplate-1.docx**

| | |
| — | — |
| SOAP NOTE TEMPLATE<br>Review the Rubric for more Guidance |
| _Demographics_ | |
| _Chief Complaint (Reason for seeking health care)_ | |
| _History of Present Illness (HPI)_ | |
| _Allergies_ | |
| _Review of Systems (ROS)_ | General: <br>HEENT:<br>Neck: <br>Lungs:<br>Cardio<br>Breast: <br>GI: <br>M/F genital:<br>GU: <br>Neuro<br>Musculo:<br>Activity:<br>Psychosocial: <br>Derm: <br>Nutrition:<br>Sleep/Rest:<br>LMP: <br>STI Hx: |
| _Vital Signs_ | |
| _Labs_ | |
| _Medications_ | |
| _Past Medical History_ | |
| _Past Surgical History_ | |
| _Family History_ | |
| _Social History_ | |
| _Health Maintenance/ Screenings_ | |
| _Physical Examination_ | General: <br>HEENT:<br>Neck: <br>Lungs:<br>Cardio<br>Breast: <br>GI: <br>M/F genital:<br>GU: <br>Neuro<br>Musculo:<br>Activity:<br>Psychosocial: <br>Derm: |
| _Diagnosis_ | |
| _Differential Diagnosis_ | |
| _ICD 10 Coding_ | |
| _Pharmacologic treatment plan_ | |
| _Diagnostic/Lab Testing_ | |
| _Education_ | |
| _Anticipatory Guidance_ | |
| _Follow up plan_ | |
| _Prescription_ | See Below (scroll down) |
| _References_ | |
| _Grammar_ | |

| |
| — |
| EA#: 101010101 STU Clinic LIC# 10000000 |
| Tel: (000) 555-1234 FAX: (000) 555-12222 |
| Patient Name: (Initials)______________________________ Age ___________<br>Date: _______________<br>RX ______________________________________<br>SIG:<br>Dispense: ___________ Refill: _________________<br>No Substitution<br> <br>Signature:____________________________________________________________ |

Signature (with appropriate credentials):_____________________________________

References (must use current evidence-based guidelines used to guide the care [Mandatory])

**## SoapNoterubric.docx**

| | |
| — | — |
| Demographics | **1 to >0.8 pts**<br>**Begins with patient initials, age, race, ethnicity and gender (5 demographics)** |
| Chief Complaint (Reason for seeking health care) | **4 to >3 pts**<br>**Includes a direct quote from patient about presenting problem** |
| History of the Present Illness (HPI) | **5 to >3 pts**<br>**Includes the presenting problem and the 8 dimensions of the problem (OLD CARTS – Onset, Location, Duration, Character, Aggravating factors, Relieving factors, Timing and Severity)** |
| Allergies | **2 to >1.5 pts**<br>**Includes NKA (including = Drug, Environmental, Food, Herbal, and/or Latex or if allergies are present (reports for each severity of allergy AND description of allergy)** |
| Review of Systems (ROS) | **2 to >1.5 pts**<br>**Includes all 8 vital signs, (BP (with patient position), HR, RR, temperature (with Fahrenheit or Celsius and route of temperature collection), weight, height, BMI (or percentiles for pediatric population) and pain.** |
| Labs | **4 to >2 pts**<br>**Includes a list of all of the patient reported medications and the medical diagnosis for the medication (including name, dose, route, frequency)** |
| Past Medical History | **3 to >2 pts**<br>**Includes (Major/Chronic, Trauma, Hospitalizations), for each medical diagnosis, year of diagnosis and whether the diagnosis is active or current** |
| Past Surgical History | **3 to >2 pts**<br>**Includes, for each surgical procedure, the year of procedure and the indication for the procedure** |

| | |
| — | — |
| Family History | **3 to >2 pts**<br>**Includes an assessment of at least 4 family members regarding, at a minimum, genetic disorders, diabetes, heart disease and cancer.** |
| Social History | **3 to >2 pts**<br>**Includes all of the required following: tobacco use, drug use, alcohol use, marital status, employment status, current/previous occupation, sexual orientation, sexually active, contraceptive use, and living situation** |
| Health Maintenance / Screenings | **3 to >2 pts**<br>**Includes a detailed assessment of immunization status and other health maintenance needs such as age-appropriate screenings and preventive measures Includes an assessment of at least 5 screening tests** |
| Physical Examination | **15 to >8 pts**<br>**Includes a minimum of 4 assessments for each body system and assesses at least 5 body systems directed to chief complaint** |
| Diagnosis | **5 to >3 pts**<br>**Includes a clear outline of the accurate principal diagnosis AND lists the remaining diagnoses addressed at the visit (in descending priority)** |
| Differential Diagnosis | **5 to >3 pts**<br>**Includes at least 3 differential diagnoses for the principal diagnosis** |
| Pharmacologic treatment plan | **5 to >3 pts**<br>**Includes a detailed pharmacologic treatment plan for each of the diagnoses listed under “assessment”. The plan includes ALL of the required following: drug name, dose, route, frequency, duration and cost as well as education related to pharmacologic agent. If the diagnosis is a chronic problem, student includes instructions on currently prescribed medications as above.** |

| | |
| — | — |
| Diagnostic / Lab Testing | **3 to >2 pts**<br>**Includes appropriate diagnostic/lab testing 100% of the time OR acknowledges “no diagnostic testing clinically required at this time”** |
| Education | **3 to >2 pts**<br>**Includes at least 3 strategies to promote and develop skills for managing their illness and at least 3 self-management methods on how to incorporate healthy behaviors into their lives** |
| Anticipatory Guidance | **3 to >2 pts**<br>**Includes at least 3 primary prevention strategies (related to age/condition (i.e. immunizations, pediatric and pre-natal milestone anticipatory guidance)) and at least 2 secondary prevention strategies (related to age/condition (i.e. screening))** |
| Follow Up Plan | **2 to >1 pts**<br>**Includes recommendation for follow up, including time frame (i.e. x # of days/weeks/months)** |
| Prescription | **3 to >2 pts**<br>**Prescription includes all required components: patient information, date, drug name, dose, route, frequency, quantity to be dispensed, refills, and provider’s signature and credentials** |

| | |
| — | — |
| Writing Mechanics, Citations, and APA Style | **3 to >2 pts**<br>**Effectively uses the literature and other resources to inform their work. Exceptional use of citations and extended referencing. APA style is correct, and writing is free of grammar and spelling errors.** |

**## SoapNoterubric.docx**

| | |
| — | — |
| Demographics | **1 to >0.8 pts**<br>**Begins with patient initials, age, race, ethnicity and gender (5 demographics)** |
| Chief Complaint (Reason for seeking health care) | **4 to >3 pts**<br>**Includes a direct quote from patient about presenting problem** |
| History of the Present Illness (HPI) | **5 to >3 pts**<br>**Includes the presenting problem and the 8 dimensions of the problem (OLD CARTS – Onset, Location, Duration, Character, Aggravating factors, Relieving factors, Timing and Severity)** |
| Allergies | **2 to >1.5 pts**<br>**Includes NKA (including = Drug, Environmental, Food, Herbal, and/or Latex or if allergies are present (reports for each severity of allergy AND description of allergy)** |
| Review of Systems (ROS) | **2 to >1.5 pts**<br>**Includes all 8 vital signs, (BP (with patient position), HR, RR, temperature (with Fahrenheit or Celsius and route of temperature collection), weight, height, BMI (or percentiles for pediatric population) and pain.** |
| Labs | **4 to >2 pts**<br>**Includes a list of all of the patient reported medications and the medical diagnosis for the medication (including name, dose, route, frequency)** |
| Past Medical History | **3 to >2 pts**<br>**Includes (Major/Chronic, Trauma, Hospitalizations), for each medical diagnosis, year of diagnosis and whether the diagnosis is active or current** |
| Past Surgical History | **3 to >2 pts**<br>**Includes, for each surgical procedure, the year of procedure and the indication for the procedure** |

| | |
| — | — |
| Family History | **3 to >2 pts**<br>**Includes an assessment of at least 4 family members regarding, at a minimum, genetic disorders, diabetes, heart disease and cancer.** |
| Social History | **3 to >2 pts**<br>**Includes all of the required following: tobacco use, drug use, alcohol use, marital status, employment status, current/previous occupation, sexual orientation, sexually active, contraceptive use, and living situation** |
| Health Maintenance / Screenings | **3 to >2 pts**<br>**Includes a detailed assessment of immunization status and other health maintenance needs such as age-appropriate screenings and preventive measures Includes an assessment of at least 5 screening tests** |
| Physical Examination | **15 to >8 pts**<br>**Includes a minimum of 4 assessments for each body system and assesses at least 5 body systems directed to chief complaint** |
| Diagnosis | **5 to >3 pts**<br>**Includes a clear outline of the accurate principal diagnosis AND lists the remaining diagnoses addressed at the visit (in descending priority)** |
| Differential Diagnosis | **5 to >3 pts**<br>**Includes at least 3 differential diagnoses for the principal diagnosis** |
| Pharmacologic treatment plan | **5 to >3 pts**<br>**Includes a detailed pharmacologic treatment plan for each of the diagnoses listed under “assessment”. The plan includes ALL of the required following: drug name, dose, route, frequency, duration and cost as well as education related to pharmacologic agent. If the diagnosis is a chronic problem, student includes instructions on currently prescribed medications as above.** |

| | |
| — | — |
| Diagnostic / Lab Testing | **3 to >2 pts**<br>**Includes appropriate diagnostic/lab testing 100% of the time OR acknowledges “no diagnostic testing clinically required at this time”** |
| Education | **3 to >2 pts**<br>**Includes at least 3 strategies to promote and develop skills for managing their illness and at least 3 self-management methods on how to incorporate healthy behaviors into their lives** |
| Anticipatory Guidance | **3 to >2 pts**<br>**Includes at least 3 primary prevention strategies (related to age/condition (i.e. immunizations, pediatric and pre-natal milestone anticipatory guidance)) and at least 2 secondary prevention strategies (related to age/condition (i.e. screening))** |
| Follow Up Plan | **2 to >1 pts**<br>**Includes recommendation for follow up, including time frame (i.e. x # of days/weeks/months)** |
| Prescription | **3 to >2 pts**<br>**Prescription includes all required components: patient information, date, drug name, dose, route, frequency, quantity to be dispensed, refills, and provider’s signature and credentials** |

| | |
| — | — |
| Writing Mechanics, Citations, and APA Style | **3 to >2 pts**<br>**Effectively uses the literature and other resources to inform their work. Exceptional use of citations and extended referencing. APA style is correct, and writing is free of grammar and spelling errors.** |

**## ASOAPnoteisamethodofdocumentationemployedbyhealthcareproviderstorecordandcommunicatepatientinformationinaclear.docx**

A SOAP note is a method of documentation employed by healthcare providers to record and communicate patient information in a clear, structured, and in an organized manner. This assignment will provide students with the necessary tools to document patient care effectively, enhance their clinical skills, and prepare them for their roles as competent healthcare providers.

**Instructions:**

SOAP is an acronym that stands for Subjective, Objective, Assessment, and Plan. The episodic SOAP note is to be written using the attached template below.

For all the SOAP note assignments, you will write a SOAP note about one of your patients and use the following acronym:

| | |
| — | — |
| **S** = | Subjective data: Patient’s Chief Complaint (CC). |
| **O** = | Objective data: Including client behavior, physical assessment, vital signs, and meds. |
| **A** = | Assessment: Diagnosis of the patient's condition. Include differential diagnosis. |
| **P** = | Plan: Treatment, diagnostic testing, and follow up |

**## SOAPNoteTemplate-1.docx**

| | |
| — | — |
| SOAP NOTE TEMPLATE<br>Review the Rubric for more Guidance |
| _Demographics_ | |
| _Chief Complaint (Reason for seeking health care)_ | |
| _History of Present Illness (HPI)_ | |
| _Allergies_ | |
| _Review of Systems (ROS)_ | General: <br>HEENT:<br>Neck: <br>Lungs:<br>Cardio<br>Breast: <br>GI: <br>M/F genital:<br>GU: <br>Neuro<br>Musculo:<br>Activity:<br>Psychosocial: <br>Derm: <br>Nutrition:<br>Sleep/Rest:<br>LMP: <br>STI Hx: |
| _Vital Signs_ | |
| _Labs_ | |
| _Medications_ | |
| _Past Medical History_ | |
| _Past Surgical History_ | |
| _Family History_ | |
| _Social History_ | |
| _Health Maintenance/ Screenings_ | |
| _Physical Examination_ | General: <br>HEENT:<br>Neck: <br>Lungs:<br>Cardio<br>Breast: <br>GI: <br>M/F genital:<br>GU: <br>Neuro<br>Musculo:<br>Activity:<br>Psychosocial: <br>Derm: |
| _Diagnosis_ | |
| _Differential Diagnosis_ | |
| _ICD 10 Coding_ | |
| _Pharmacologic treatment plan_ | |
| _Diagnostic/Lab Testing_ | |
| _Education_ | |
| _Anticipatory Guidance_ | |
| _Follow up plan_ | |
| _Prescription_ | See Below (scroll down) |
| _References_ | |
| _Grammar_ | |

| |
| — |
| EA#: 101010101 STU Clinic LIC# 10000000 |
| Tel: (000) 555-1234 FAX: (000) 555-12222 |
| Patient Name: (Initials)______________________________ Age ___________<br>Date: _______________<br>RX ______________________________________<br>SIG:<br>Dispense: ___________ Refill: _________________<br>No Substitution<br> <br>Signature:____________________________________________________________ |

Signature (with appropriate credentials):_____________________________________

References (must use current evidence-based guidelines used to guide the care [Mandatory])

**## SoapNoterubric.docx**

| | |
| — | — |
| Demographics | **1 to >0.8 pts**<br>**Begins with patient initials, age, race, ethnicity and gender (5 demographics)** |
| Chief Complaint (Reason for seeking health care) | **4 to >3 pts**<br>**Includes a direct quote from patient about presenting problem** |
| History of the Present Illness (HPI) | **5 to >3 pts**<br>**Includes the presenting problem and the 8 dimensions of the problem (OLD CARTS – Onset, Location, Duration, Character, Aggravating factors, Relieving factors, Timing and Severity)** |
| Allergies | **2 to >1.5 pts**<br>**Includes NKA (including = Drug, Environmental, Food, Herbal, and/or Latex or if allergies are present (reports for each severity of allergy AND description of allergy)** |
| Review of Systems (ROS) | **2 to >1.5 pts**<br>**Includes all 8 vital signs, (BP (with patient position), HR, RR, temperature (with Fahrenheit or Celsius and route of temperature collection), weight, height, BMI (or percentiles for pediatric population) and pain.** |
| Labs | **4 to >2 pts**<br>**Includes a list of all of the patient reported medications and the medical diagnosis for the medication (including name, dose, route, frequency)** |
| Past Medical History | **3 to >2 pts**<br>**Includes (Major/Chronic, Trauma, Hospitalizations), for each medical diagnosis, year of diagnosis and whether the diagnosis is active or current** |
| Past Surgical History | **3 to >2 pts**<br>**Includes, for each surgical procedure, the year of procedure and the indication for the procedure** |

| | |
| — | — |
| Family History | **3 to >2 pts**<br>**Includes an assessment of at least 4 family members regarding, at a minimum, genetic disorders, diabetes, heart disease and cancer.** |
| Social History | **3 to >2 pts**<br>**Includes all of the required following: tobacco use, drug use, alcohol use, marital status, employment status, current/previous occupation, sexual orientation, sexually active, contraceptive use, and living situation** |
| Health Maintenance / Screenings | **3 to >2 pts**<br>**Includes a detailed assessment of immunization status and other health maintenance needs such as age-appropriate screenings and preventive measures Includes an assessment of at least 5 screening tests** |
| Physical Examination | **15 to >8 pts**<br>**Includes a minimum of 4 assessments for each body system and assesses at least 5 body systems directed to chief complaint** |
| Diagnosis | **5 to >3 pts**<br>**Includes a clear outline of the accurate principal diagnosis AND lists the remaining diagnoses addressed at the visit (in descending priority)** |
| Differential Diagnosis | **5 to >3 pts**<br>**Includes at least 3 differential diagnoses for the principal diagnosis** |
| Pharmacologic treatment plan | **5 to >3 pts**<br>**Includes a detailed pharmacologic treatment plan for each of the diagnoses listed under “assessment”. The plan includes ALL of the required following: drug name, dose, route, frequency, duration and cost as well as education related to pharmacologic agent. If the diagnosis is a chronic problem, student includes instructions on currently prescribed medications as above.** |

| | |
| — | — |
| Diagnostic / Lab Testing | **3 to >2 pts**<br>**Includes appropriate diagnostic/lab testing 100% of the time OR acknowledges “no diagnostic testing clinically required at this time”** |
| Education | **3 to >2 pts**<br>**Includes at least 3 strategies to promote and develop skills for managing their illness and at least 3 self-management methods on how to incorporate healthy behaviors into their lives** |
| Anticipatory Guidance | **3 to >2 pts**<br>**Includes at least 3 primary prevention strategies (related to age/condition (i.e. immunizations, pediatric and pre-natal milestone anticipatory guidance)) and at least 2 secondary prevention strategies (related to age/condition (i.e. screening))** |
| Follow Up Plan | **2 to >1 pts**<br>**Includes recommendation for follow up, including time frame (i.e. x # of days/weeks/months)** |
| Prescription | **3 to >2 pts**<br>**Prescription includes all required components: patient information, date, drug name, dose, route, frequency, quantity to be dispensed, refills, and provider’s signature and credentials** |

| | |
| — | — |
| Writing Mechanics, Citations, and APA Style | **3 to >2 pts**<br>**Effectively uses the literature and other resources to inform their work. Exceptional use of citations and extended referencing. APA style is correct, and writing is free of grammar and spelling errors.** |

**## ASOAPnoteisamethodofdocumentationemployedbyhealthcareproviderstorecordandcommunicatepatientinformationinaclear.docx**

A SOAP note is a method of documentation employed by healthcare providers to record and communicate patient information in a clear, structured, and in an organized manner. This assignment will provide students with the necessary tools to document patient care effectively, enhance their clinical skills, and prepare them for their roles as competent healthcare providers.

**Instructions:**

SOAP is an acronym that stands for Subjective, Objective, Assessment, and Plan. The episodic SOAP note is to be written using the attached template below.

For all the SOAP note assignments, you will write a SOAP note about one of your patients and use the following acronym:

| | |
| — | — |
| **S** = | Subjective data: Patient’s Chief Complaint (CC). |
| **O** = | Objective data: Including client behavior, physical assessment, vital signs, and meds. |
| **A** = | Assessment: Diagnosis of the patient's condition. Include differential diagnosis. |
| **P** = | Plan: Treatment, diagnostic testing, and follow up |

**## SOAPNoteTemplate-1.docx**

| | |
| — | — |
| SOAP NOTE TEMPLATE<br>Review the Rubric for more Guidance |
| _Demographics_ | |
| _Chief Complaint (Reason for seeking health care)_ | |
| _History of Present Illness (HPI)_ | |
| _Allergies_ | |
| _Review of Systems (ROS)_ | General: <br>HEENT:<br>Neck: <br>Lungs:<br>Cardio<br>Breast: <br>GI: <br>M/F genital:<br>GU: <br>Neuro<br>Musculo:<br>Activity:<br>Psychosocial: <br>Derm: <br>Nutrition:<br>Sleep/Rest:<br>LMP: <br>STI Hx: |
| _Vital Signs_ | |
| _Labs_ | |
| _Medications_ | |
| _Past Medical History_ | |
| _Past Surgical History_ | |
| _Family History_ | |
| _Social History_ | |
| _Health Maintenance/ Screenings_ | |
| _Physical Examination_ | General: <br>HEENT:<br>Neck: <br>Lungs:<br>Cardio<br>Breast: <br>GI: <br>M/F genital:<br>GU: <br>Neuro<br>Musculo:<br>Activity:<br>Psychosocial: <br>Derm: |
| _Diagnosis_ | |
| _Differential Diagnosis_ | |
| _ICD 10 Coding_ | |
| _Pharmacologic treatment plan_ | |
| _Diagnostic/Lab Testing_ | |
| _Education_ | |
| _Anticipatory Guidance_ | |
| _Follow up plan_ | |
| _Prescription_ | See Below (scroll down) |
| _References_ | |
| _Grammar_ | |

| |
| — |
| EA#: 101010101 STU Clinic LIC# 10000000 |
| Tel: (000) 555-1234 FAX: (000) 555-12222 |
| Patient Name: (Initials)______________________________ Age ___________<br>Date: _______________<br>RX ______________________________________<br>SIG:<br>Dispense: ___________ Refill: _________________<br>No Substitution<br> <br>Signature:____________________________________________________________ |

Signature (with appropriate credentials):_____________________________________

References (must use current evidence-based guidelines used to guide the care [Mandatory])

**## SoapNoterubric.docx**

| | |
| — | — |
| Demographics | **1 to >0.8 pts**<br>**Begins with patient initials, age, race, ethnicity and gender (5 demographics)** |
| Chief Complaint (Reason for seeking health care) | **4 to >3 pts**<br>**Includes a direct quote from patient about presenting problem** |
| History of the Present Illness (HPI) | **5 to >3 pts**<br>**Includes the presenting problem and the 8 dimensions of the problem (OLD CARTS – Onset, Location, Duration, Character, Aggravating factors, Relieving factors, Timing and Severity)** |
| Allergies | **2 to >1.5 pts**<br>**Includes NKA (including = Drug, Environmental, Food, Herbal, and/or Latex or if allergies are present (reports for each severity of allergy AND description of allergy)** |
| Review of Systems (ROS) | **2 to >1.5 pts**<br>**Includes all 8 vital signs, (BP (with patient position), HR, RR, temperature (with Fahrenheit or Celsius and route of temperature collection), weight, height, BMI (or percentiles for pediatric population) and pain.** |
| Labs | **4 to >2 pts**<br>**Includes a list of all of the patient reported medications and the medical diagnosis for the medication (including name, dose, route, frequency)** |
| Past Medical History | **3 to >2 pts**<br>**Includes (Major/Chronic, Trauma, Hospitalizations), for each medical diagnosis, year of diagnosis and whether the diagnosis is active or current** |
| Past Surgical History | **3 to >2 pts**<br>**Includes, for each surgical procedure, the year of procedure and the indication for the procedure** |

| | |
| — | — |
| Family History | **3 to >2 pts**<br>**Includes an assessment of at least 4 family members regarding, at a minimum, genetic disorders, diabetes, heart disease and cancer.** |
| Social History | **3 to >2 pts**<br>**Includes all of the required following: tobacco use, drug use, alcohol use, marital status, employment status, current/previous occupation, sexual orientation, sexually active, contraceptive use, and living situation** |
| Health Maintenance / Screenings | **3 to >2 pts**<br>**Includes a detailed assessment of immunization status and other health maintenance needs such as age-appropriate screenings and preventive measures Includes an assessment of at least 5 screening tests** |
| Physical Examination | **15 to >8 pts**<br>**Includes a minimum of 4 assessments for each body system and assesses at least 5 body systems directed to chief complaint** |
| Diagnosis | **5 to >3 pts**<br>**Includes a clear outline of the accurate principal diagnosis AND lists the remaining diagnoses addressed at the visit (in descending priority)** |
| Differential Diagnosis | **5 to >3 pts**<br>**Includes at least 3 differential diagnoses for the principal diagnosis** |
| Pharmacologic treatment plan | **5 to >3 pts**<br>**Includes a detailed pharmacologic treatment plan for each of the diagnoses listed under “assessment”. The plan includes ALL of the required following: drug name, dose, route, frequency, duration and cost as well as education related to pharmacologic agent. If the diagnosis is a chronic problem, student includes instructions on currently prescribed medications as above.** |

| | |
| — | — |
| Diagnostic / Lab Testing | **3 to >2 pts**<br>**Includes appropriate diagnostic/lab testing 100% of the time OR acknowledges “no diagnostic testing clinically required at this time”** |
| Education | **3 to >2 pts**<br>**Includes at least 3 strategies to promote and develop skills for managing their illness and at least 3 self-management methods on how to incorporate healthy behaviors into their lives** |
| Anticipatory Guidance | **3 to >2 pts**<br>**Includes at least 3 primary prevention strategies (related to age/condition (i.e. immunizations, pediatric and pre-natal milestone anticipatory guidance)) and at least 2 secondary prevention strategies (related to age/condition (i.e. screening))** |
| Follow Up Plan | **2 to >1 pts**<br>**Includes recommendation for follow up, including time frame (i.e. x # of days/weeks/months)** |
| Prescription | **3 to >2 pts**<br>**Prescription includes all required components: patient information, date, drug name, dose, route, frequency, quantity to be dispensed, refills, and provider’s signature and credentials** |

| | |
| — | — |
| Writing Mechanics, Citations, and APA Style | **3 to >2 pts**<br>**Effectively uses the literature and other resources to inform their work. Exceptional use of citations and extended referencing. APA style is correct, and writing is free of grammar and spelling errors.** |

November 5, 2026
[Solved] NUR 506 W3

✓ Verified Academic Solution Available

Executive Solution Overview

– a year ago **files (1)** – ## NUR506W3.docx **## NUR506W3.docx** **DISCUSSION:** What components of the ACA do you think will have a positive effect on improving health care outcomes and decreasing costs? **INSTRUCTIONS:** · Your initial post should be at least 500 words, formatted and cited in cu…

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Assignment Prompt & Instructions

– a year ago

**files (1)**

– ## NUR506W3.docx

**## NUR506W3.docx**

**DISCUSSION:**

What components of the ACA do you think will have a positive effect on improving health care outcomes and decreasing costs?

**INSTRUCTIONS:**

· Your initial post should be at least 500 words, formatted and cited in current APA style with support from at least 2 academic sources. Your initial post is worth 8 points.

· Please include introduction and conclusion paragraphs

· Please write in paragraph form, no bullet points

· Please do not use textbooks as reference only peer-reviewed scholarly articles from within 4 years’ time.

· Please ensure APA formatting is correct

![A screenshot of a white sheet AI-generated content may be incorrect.](https://www.sweetstudy.com/questions/nur-506-w3)

## image1.png

**## NUR506W3.docx**

**DISCUSSION:**

What components of the ACA do you think will have a positive effect on improving health care outcomes and decreasing costs?

**INSTRUCTIONS:**

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November 5, 2026
[Solved] NUR 505 W3

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– a year ago **files (1)** – ## NUR505W3.docx **## NUR505W3.docx** **DISCUSSION:** A. Describe health and illness practices that may augment problems associated with the treatment of hypertension for Chinese-American clients. B. Describe the locus-of-control variable that some Filipino Americans hav…

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– a year ago

**files (1)**

– ## NUR505W3.docx

**## NUR505W3.docx**

**DISCUSSION:**

A. Describe health and illness practices that may augment problems associated with the treatment of hypertension for Chinese-American clients.

B. Describe the locus-of-control variable that some Filipino Americans have that may influence health-seeking behavior.

C. Describe the importance of folk medicine and folk healers to Vietnamese Americans.

**INSTRUCTIONS:**

· Your initial post should be at least 500 words, formatted and cited in current APA style with support from at least 2 academic sources. Your initial post is worth 8 points.

· Please include introduction and conclusion paragraphs

· Please write in paragraph form, no bullet points

· Incorporate a minimum of 2 current (published within the last five years) scholarly journal articles or primary legal sources (statutes, court opinions) within your work. Journal articles should be referenced according to the current APA style (the online library has an abbreviated version of the APA Manual).

· Please ensure APA formatting is correct

PLEASE SEE RUBRIC BELOW FOR SCORE OF 10 POINTS

![A screenshot of a white sheet AI-generated content may be incorrect.](https://www.sweetstudy.com/questions/nur-505-w3)

## image1.png

**## NUR505W3.docx**

**DISCUSSION:**

A. Describe health and illness practices that may augment problems associated with the treatment of hypertension for Chinese-American clients.

B. Describe the locus-of-control variable that some Filipino Americans have that may influence health-seeking behavior.

C. Describe the importance of folk medicine and folk healers to Vietnamese Americans.

**INSTRUCTIONS:**

· Your initial post should be at least 500 words, formatted and cited in current APA style with support from at least 2 academic sources. Your initial post is worth 8 points.

· Please include introduction and conclusion paragraphs

· Please write in paragraph form, no bullet points

· Incorporate a minimum of 2 current (published within the last five years) scholarly journal articles or primary legal sources (statutes, court opinions) within your work. Journal articles should be referenced according to the current APA style (the online library has an abbreviated version of the APA Manual).

· Please ensure APA formatting is correct

PLEASE SEE RUBRIC BELOW FOR SCORE OF 10 POINTS

![A screenshot of a white sheet AI-generated content may be incorrect.](https://www.sweetstudy.com/questions/nur-505-w3)

## image1.png

November 5, 2026
[Solved] medicinal cannabis, its uses, STATE BY STATE USA

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medicinal cannabis, its uses, and state regulations about its usage. At the end, explain which would be policy you would like to develop for better management of medicinal cannabis. – a year ago

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medicinal cannabis, its uses, and state regulations about its usage. At the end, explain which would be policy you would like to develop for better management of medicinal cannabis.

– a year ago

November 5, 2026
[Solved] week 4 peds soap note. Well child visit

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SOAP note well visit child. APA format. Use evidence based practice and CDC recommendations due in 30 hours. Follow the template and rubric – [\ \ PEDSSOAPNoteTemplateweek4.docx](https://www.sweetstudy.com/files/pedssoapnotetemplateweek4-docx "PEDSSOAPNoteTemplateweek4.docx") – [\ \ Soapnotechec…

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SOAP note well visit child. APA format. Use evidence based practice and CDC recommendations due in 30 hours. Follow the template and rubric

– [\
\
PEDSSOAPNoteTemplateweek4.docx](https://www.sweetstudy.com/files/pedssoapnotetemplateweek4-docx "PEDSSOAPNoteTemplateweek4.docx")
– [\
\
Soapnotechecklistwellchildvisitrubric.docx](https://www.sweetstudy.com/files/soapnotechecklistwellchildvisitrubric-docx "Soapnotechecklistwellchildvisitrubric.docx")

– a year ago

November 5, 2026
[Solved] Week 4 DB response 2

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– a year ago **files (1)** – ## Week4DBresponse2.pdf **## Week4DBresponse2.pdf** Table 1 1-hour Oral Glucose Tolerance Test (OGTT) After a 50-g oral glucose load in pregnant women Table 2 Criteria for Abnormal Result on 100-g, 3-Hour Oral Glucose Tolerance Test in Pregnant Women Table 3 Define and d…

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– a year ago

**files (1)**

– ## Week4DBresponse2.pdf

**## Week4DBresponse2.pdf**

Table 1

1-hour Oral Glucose Tolerance Test (OGTT) After a 50-g oral glucose load in pregnant women

Table 2

Criteria for Abnormal Result on 100-g, 3-Hour Oral Glucose Tolerance Test in Pregnant Women

Table 3

Define and differentiate between the following Postpartum Disorders:

Normal Range (Negative) Abnormal Range (Positive)

1 hour < 140 mg/dL 130 – 140 mg/dL

Blood Sample
National Diabetes Data Group
Criteria

Carpenter and Coustan Criteria

Fasting 105 mg/dL 95 mg/dL

1 hour 190 mg/dL 180 mg/dL

2 hours 165 mg/dL 155 mg/dL

3 hours 145 mg/dL 140 mg/dL

What defines a positive 3-hour glucose tolerance test result (failed result)? Two or more
threshold glucose levels on the 3-hour test must be met or exceeded.

Definition Signs and Symptoms

Management of the
Diagnosis

Postpartum
Blues

Short-lived
mood change

Sadness, weepiness, mood
swings, irritability that occurs
in the first few days to 10
days postpartum; lasts less
than two weeks

Family support,
uninterrupted rest, exercise,
adequate fluids, nutritious
meals

Table 4

Postpartum
Depression

Depression
occurring within
the first year
postpartum that
meets standard
diagnostic
criteria; lasts
longer than two
years

Crying, feeling sad,
overwhelmed, lack of interest
in daily activities, lack of
interest in infant, feeling sub-
inadequacy

Home support, therapy

Postpartum
Obsessive-
Compulsive
Disorder

Need to perform
repetitive
physical or
mental actions

Onslaught of intrusive
thoughts or rituals SSRIs and CBT

Postpartum
Psychosis

Psychotic
episode
(delusions or
break with
reality)
occurring within
the first year
after birth

Auditory and visual
hallucinations, various
unexplained behaviors, i.e.
smelling smoke

Immediate care i.e.
emergency room

Definition

Presentation

(include Signs and
Symptoms)

Management of the
Diagnosis

Puerperal
Fever

Temp. 100.4 F or
greater during

postpartum period
caused by bacterial
infection in the
reproductive tract or
breasts

Genital tract or wound
infections

breast engorgement,
dehydration, DVT

CBC w/ diff, urine
analysis, cultures,
radiology and/or
ultrasound.

Antimicrobial therapy

Postpartum
Hematoma

Collection of blood in
the vaginal, perineal,
pelvic, or abdominal
tissue, post childbirth

Evidence of blood loss:

Decrease hematocrit

Severe perineal and/or
rectal pain

Management varies on
size.

Small hematomas can
reabsorb; moderate to
large hematomas may
need I&D

Secondary
(delayed)
Postpartum
Hemorrhage

Excessive bleeding that
occurs between 24
hours after birth until
six weeks postpartum

Hemorrhage bleeding

Masses suspicious for
retained placental
fragments

Uterotonic agents:
ergonovine,
methylergonovine,
oxytocin, a prostaglandin
analog, or tranexamic
acid. Surgical referral for
suction evacuation to stop
bleeding

Sore Nipples

The most common
reasons for abandoning
exclusive breastfeeding.

Sore, painful, cracked.

infection: exudate,
increased erythema, pus,
or dry scab

Warm compresses, green
tea bag compresses,
coconut oil, hydrogel
dressing, nipple shields,
wash nipples with soap &
water once daily, topical
mupirocin, peppermint oil,
topical low dose steroids
for inflammation;
antibiotic: Miconazole for

C. albicans

Jennifer is a G2P1, 31-year-old pregnant female at 24 weeks EGA who has come to the clinic
for her 24-week prenatal visit and recommended screening tests. Jennifer’s one hour glucose test
result is 156 mg/DL. Her BP is 118/78 T 98.7 F, P 68, RR 18, fundal height is 25 cm, no urine/
protein in urine, weight is 145 lbs at 5 lbs increased from last visit 4 weeks ago, her height is 5’
5”.

Demographic Data

• 31-year-old-female

Mastitis

Acute inflammation of
the interlobular
connective tissue of the
breast that may include
an infection. S. aureus
is the main causative
bacteria.

Erythema, pain,
swelling, fever.

Pain described as sharp,
needlelike, with burning
sensation.

Symptoms associated
with infection: fever 101
F or greater, area red,
tender, and hot; muscle
aches & malaise,
elevated heart rate,
nausea, chills, red streaks
on the breast.

Feed or pump on the
affected side. Frequent
feedings, breast
compressions, topical
ricinoleic acid; heating
pad, castor oil,

Antibiotics:

First line: Dicloxacillin or
Flucloxacillin; Cephalexin

Second line: Clindamycin
or Bactrim DS

Breast
Abscess

A potential
complication of mastitis
r/t untreated, delayed,
inadequate, or incorrect
treatment for mastitis.
Abscess formation
increases with smoking.

Hard, red, and tender
area on the breast.

If incapsulated, must be
drained either surgically or
needle aspiration. Abscess
drainage should be
cultured to determine
antibiotic sensitivity.

Continue breast feeding
and/or pumping.

Subjective

Chief Complaint (CC): 31-year-old-female, G2P1 at 24 weeks EGA, presents to the clinic for a
routine follow up 24-week prenatal visit and recommended screen tests.

History of Present Illness (HPI): 31-year-old-female, G2P1 at 24 weeks EGA, presents to the
clinic for a routine follow up 24-week prenatal visit and recommended screening tests. The one-
hour glucose test result is 156 mg/dL; the patient has gained 5 lbs in the past 4 weeks; the fundal
height is 25 cm; and POCT urine dipstick is (-) for protein.

Past Medical History (PMH):

• Medical History:
o Denies history of HTN, diabetes, elevated cholesterol
o Denies complications with previous pregnancy
o Denies abnormal pap smears
• Hospitalizations:
o Spontaneous vaginal delivery: 2023- no complications
• Medications:
o Prenatal vitamin daily
• Allergies:
o No known drug allergies
o No know food allergies
• Immunizations:
o Influenza vaccine: 10/2024
o Covid Vaccines: 2021 & 2022
o HPV Vaccines: x3 doses at 12 years old
• Preventative Health Maintenance:
o PAP: last pap at 30 years
o Eye exams: every 2 years, last exam 2024
o Dentals exam & cleaning: last dental visit 1/2025
o STI screening: at 21 years old; 2020, and at each pregnancy diagnoses: 2023 & 2025
• Family History:
o Mother: hyperlipidemia
o Father: HTN, Hyperlipidemia
o Maternal Grandmother: hyperlipidemia
o Maternal Grandfather: HTN, Hyperlipidemia
o Paternal Grandmother: hyperlipidemia

o Paternal Grandfather: HTN, DM Type II
o Maternal great-grandmother: hyperlipidemia
o Maternal great-grandfather: HTN, Hyperlipidemia
o Paternal great-grandmother: Hypertension
o Paternal great-grandfather: HTN, DM Type II
• Social History:
o Nutrition: Eats a balanced diet and occasional take out
o Exercise: denies
o Denies history of illegal drug use
o Sexual history: 2 lifetime partners; 1 partner for the past 5 years
o Sexual intercourse with males
o History of STIs: denies
o Contraception: male condoms
o Menstrual history: 1st menstrual cycle at 13 years old
o Occupation: Elementary school teacher
o Caffeine: Green and black tea
o Smoking: denies cigarette and vaping
o Alcohol: 2-3 glasses a week prior to pregnancy

Review of Symptoms:

• General: denies fever/chills, (+) fatigue, (+) increased thirst
• Psychological: denies anxiety and depression
• Neurological: denies headaches and dizziness
• Eyes: denies blurry vision
• Ears: denies ringing in ears
• Nose, Mouth, and Throat: denies nasal congestion, dry mouth, sore throat
• Cardiology: denies chest pain
• Respiratory: denies shortness of breath
• Breast: denies breast pain
• Gastrointestinal: denies abdominal pain, nausea/vomiting, diarrhea, constipation, heartburn
• Genitourinary: denies burning; (+) frequency and urgency
• Musculoskeletal: denies muscle, joint, back pain
• Skin: denies itching
• Gynecological: Denies discharge, bleeding, pelvic cramping, leaking of fluids; denies

Braxton Hicks
• Heme/Lymph/Endo: denies heat/cold intolerance

Objective:

Vital signs: B/P: 118/78; HR: 68; T: 98.7 F; RR: 18

Pain: 0/10

Pre-pregnancy weight: 120 lb; Height: 65 inches; BMI: 20.0

Current weight 145 lbs

Pregnancy gain: + 5 lbs in 4 weeks

One hour glucose test result: 156 mg/dL. Positive result

POCT: Urine dipstick: (-) protein

Physical exam:

• Generalized: age appropriate, well developed, well-nourished, no acute distress
• Neurological: alert and oriented
• Cardiology: no swelling noted to BLE, no murmur
• Pulmonary: regular respiratory rate; chest symmetric, no wheezing
• Gastrointestinal: abdomen round; non-tender
• Musculoskeletal: upper and lower extremities, full range of motion; stable gait
• Integumentary: warm and dry
• Psychiatric: calm and cooperative
• Genitourinary: urine clear, no odor
• Gynecological: no vaginal redness or discharge noted
• Fundal height: 25cm (acceptable 22-26 cm)

OB Abdominal ultrasound:

• Intrauterine pregnancy singleton
• Presentation: Vertex
• Fetal cardiac activity present; HR 144
• Amniotic fluid appears adequate
• Fetal movements: Yes
• Fetal breathing movements: Yes

Differential Diagnosis

(1) Urinary tract infection:

• Positives: frequency, urgency, pregnancy
• Negatives: urine clear, no odor, no fevers/chills, no low abdominal/back pain

Final Diagnosis

(1) Gestational diabetes (GD):

• Positives: maternal age > 25, weight gain +5 lbs in 4 weeks, 1-hr glucose teat 156, fatigue,
increased thirst, increased urinary frequency and urgency

Plan:

Diagnostic testing

• Urine POCT in office: to r/o UTI: negative for nitrite and/or leukocyte
• NST: monitors fetal heart rate in response to their movement
• CBC: monitor WBC & platelets, can increase with GD.
• 3-hour 100-g OGTT Glucose challenge: to diagnose GD

Medications:

Continue: Prenatal vitamin: Take 1 tablet by mouth daily.

Vaccine: Tdap

Education:

• Normal weight pre-pregnancy: weight gain 1 lb /week during 2nd – 3rd trimester.
• Complications of GDM if noncompliant
o Maternal: Risk of high blood pressure, preeclampsia, pre-term labor, spontaneous abortion
o Fetus: microsomia, macrosomia (makes delivery difficult), still birth
o Newborn: elevated bilirubin causes jaundice, hypocalcemia, polycythemia, hypoglycemia
• Exercise 30 minutes daily 5 times a week, such as walking
• Limit carbohydrates
• Eat 3 meals and 2 snacks
• Monitor blood glucose at home 4-6 times per day: before meals, and 2 hours after
• 3-hour 100-g OGTT: in the morning after fasting overnight
• Management for Class GDMA1:
o diet, exercise, blood glucose monitoring
• Management for Class GDMA2
o Starting with Metformin 500mg by mouth once a day for one week, then increase to 500 mg

to twice a day to decrease side effects
o Can increase 500 mg every week to a maximum of 2500 ng
o Most common side effects of Metformin: abdominal pain & diarrhea
• Insulin
o Recommended for BMI > 40

o Serious risk factor is hypoglycemia which can lead to coma or death if not treated
immediately

o Symptoms of hypoglycemia: shaking, sweating, agitation, rapid heart rate, clammy skin
o Blood glucose < 80 should be treated with 15 gm of glucose
• Monitor for type DM and insulin resistance after delivery

Referral/Follow-up

• Referral to dietician or diabetes educator- if positive
• Week 28 visit:
o NST:
o Urogynecology for pelvic floor evaluation, exercises
o Transabdominal ultrasound
o Amniotic fluid index (AFI)
o POCT: urine dipstick
• RSV: recommended at 28 weeks to protect the infant from RSV
• Tdap: recommended between 27-36 weeks to protect against pertussis (whooping cough)

Health Maintenance:

• Vision exams: every 2 years- 2026
• Dental exams/cleaning: 2 per year- 7/2025
• Pap: 33 years old
• Vaccines: 10/2025: annual influenza

**## Week4DBresponse2.pdf**

Table 1

1-hour Oral Glucose Tolerance Test (OGTT) After a 50-g oral glucose load in pregnant women

Table 2

Criteria for Abnormal Result on 100-g, 3-Hour Oral Glucose Tolerance Test in Pregnant Women

Table 3

Define and differentiate between the following Postpartum Disorders:

Normal Range (Negative) Abnormal Range (Positive)

1 hour < 140 mg/dL 130 – 140 mg/dL

Blood Sample
National Diabetes Data Group
Criteria

Carpenter and Coustan Criteria

Fasting 105 mg/dL 95 mg/dL

1 hour 190 mg/dL 180 mg/dL

2 hours 165 mg/dL 155 mg/dL

3 hours 145 mg/dL 140 mg/dL

What defines a positive 3-hour glucose tolerance test result (failed result)? Two or more
threshold glucose levels on the 3-hour test must be met or exceeded.

Definition Signs and Symptoms

Management of the
Diagnosis

Postpartum
Blues

Short-lived
mood change

Sadness, weepiness, mood
swings, irritability that occurs
in the first few days to 10
days postpartum; lasts less
than two weeks

Family support,
uninterrupted rest, exercise,
adequate fluids, nutritious
meals

Table 4

Postpartum
Depression

Depression
occurring within
the first year
postpartum that
meets standard
diagnostic
criteria; lasts
longer than two
years

Crying, feeling sad,
overwhelmed, lack of interest
in daily activities, lack of
interest in infant, feeling sub-
inadequacy

Home support, therapy

Postpartum
Obsessive-
Compulsive
Disorder

Need to perform
repetitive
physical or
mental actions

Onslaught of intrusive
thoughts or rituals SSRIs and CBT

Postpartum
Psychosis

Psychotic
episode
(delusions or
break with
reality)
occurring within
the first year
after birth

Auditory and visual
hallucinations, various
unexplained behaviors, i.e.
smelling smoke

Immediate care i.e.
emergency room

Definition

Presentation

(include Signs and
Symptoms)

Management of the
Diagnosis

Puerperal
Fever

Temp. 100.4 F or
greater during

postpartum period
caused by bacterial
infection in the
reproductive tract or
breasts

Genital tract or wound
infections

breast engorgement,
dehydration, DVT

CBC w/ diff, urine
analysis, cultures,
radiology and/or
ultrasound.

Antimicrobial therapy

Postpartum
Hematoma

Collection of blood in
the vaginal, perineal,
pelvic, or abdominal
tissue, post childbirth

Evidence of blood loss:

Decrease hematocrit

Severe perineal and/or
rectal pain

Management varies on
size.

Small hematomas can
reabsorb; moderate to
large hematomas may
need I&D

Secondary
(delayed)
Postpartum
Hemorrhage

Excessive bleeding that
occurs between 24
hours after birth until
six weeks postpartum

Hemorrhage bleeding

Masses suspicious for
retained placental
fragments

Uterotonic agents:
ergonovine,
methylergonovine,
oxytocin, a prostaglandin
analog, or tranexamic
acid. Surgical referral for
suction evacuation to stop
bleeding

Sore Nipples

The most common
reasons for abandoning
exclusive breastfeeding.

Sore, painful, cracked.

infection: exudate,
increased erythema, pus,
or dry scab

Warm compresses, green
tea bag compresses,
coconut oil, hydrogel
dressing, nipple shields,
wash nipples with soap &
water once daily, topical
mupirocin, peppermint oil,
topical low dose steroids
for inflammation;
antibiotic: Miconazole for

C. albicans

Jennifer is a G2P1, 31-year-old pregnant female at 24 weeks EGA who has come to the clinic
for her 24-week prenatal visit and recommended screening tests. Jennifer’s one hour glucose test
result is 156 mg/DL. Her BP is 118/78 T 98.7 F, P 68, RR 18, fundal height is 25 cm, no urine/
protein in urine, weight is 145 lbs at 5 lbs increased from last visit 4 weeks ago, her height is 5’
5”.

Demographic Data

• 31-year-old-female

Mastitis

Acute inflammation of
the interlobular
connective tissue of the
breast that may include
an infection. S. aureus
is the main causative
bacteria.

Erythema, pain,
swelling, fever.

Pain described as sharp,
needlelike, with burning
sensation.

Symptoms associated
with infection: fever 101
F or greater, area red,
tender, and hot; muscle
aches & malaise,
elevated heart rate,
nausea, chills, red streaks
on the breast.

Feed or pump on the
affected side. Frequent
feedings, breast
compressions, topical
ricinoleic acid; heating
pad, castor oil,

Antibiotics:

First line: Dicloxacillin or
Flucloxacillin; Cephalexin

Second line: Clindamycin
or Bactrim DS

Breast
Abscess

A potential
complication of mastitis
r/t untreated, delayed,
inadequate, or incorrect
treatment for mastitis.
Abscess formation
increases with smoking.

Hard, red, and tender
area on the breast.

If incapsulated, must be
drained either surgically or
needle aspiration. Abscess
drainage should be
cultured to determine
antibiotic sensitivity.

Continue breast feeding
and/or pumping.

Subjective

Chief Complaint (CC): 31-year-old-female, G2P1 at 24 weeks EGA, presents to the clinic for a
routine follow up 24-week prenatal visit and recommended screen tests.

History of Present Illness (HPI): 31-year-old-female, G2P1 at 24 weeks EGA, presents to the
clinic for a routine follow up 24-week prenatal visit and recommended screening tests. The one-
hour glucose test result is 156 mg/dL; the patient has gained 5 lbs in the past 4 weeks; the fundal
height is 25 cm; and POCT urine dipstick is (-) for protein.

Past Medical History (PMH):

• Medical History:
o Denies history of HTN, diabetes, elevated cholesterol
o Denies complications with previous pregnancy
o Denies abnormal pap smears
• Hospitalizations:
o Spontaneous vaginal delivery: 2023- no complications
• Medications:
o Prenatal vitamin daily
• Allergies:
o No known drug allergies
o No know food allergies
• Immunizations:
o Influenza vaccine: 10/2024
o Covid Vaccines: 2021 & 2022
o HPV Vaccines: x3 doses at 12 years old
• Preventative Health Maintenance:
o PAP: last pap at 30 years
o Eye exams: every 2 years, last exam 2024
o Dentals exam & cleaning: last dental visit 1/2025
o STI screening: at 21 years old; 2020, and at each pregnancy diagnoses: 2023 & 2025
• Family History:
o Mother: hyperlipidemia
o Father: HTN, Hyperlipidemia
o Maternal Grandmother: hyperlipidemia
o Maternal Grandfather: HTN, Hyperlipidemia
o Paternal Grandmother: hyperlipidemia

o Paternal Grandfather: HTN, DM Type II
o Maternal great-grandmother: hyperlipidemia
o Maternal great-grandfather: HTN, Hyperlipidemia
o Paternal great-grandmother: Hypertension
o Paternal great-grandfather: HTN, DM Type II
• Social History:
o Nutrition: Eats a balanced diet and occasional take out
o Exercise: denies
o Denies history of illegal drug use
o Sexual history: 2 lifetime partners; 1 partner for the past 5 years
o Sexual intercourse with males
o History of STIs: denies
o Contraception: male condoms
o Menstrual history: 1st menstrual cycle at 13 years old
o Occupation: Elementary school teacher
o Caffeine: Green and black tea
o Smoking: denies cigarette and vaping
o Alcohol: 2-3 glasses a week prior to pregnancy

Review of Symptoms:

• General: denies fever/chills, (+) fatigue, (+) increased thirst
• Psychological: denies anxiety and depression
• Neurological: denies headaches and dizziness
• Eyes: denies blurry vision
• Ears: denies ringing in ears
• Nose, Mouth, and Throat: denies nasal congestion, dry mouth, sore throat
• Cardiology: denies chest pain
• Respiratory: denies shortness of breath
• Breast: denies breast pain
• Gastrointestinal: denies abdominal pain, nausea/vomiting, diarrhea, constipation, heartburn
• Genitourinary: denies burning; (+) frequency and urgency
• Musculoskeletal: denies muscle, joint, back pain
• Skin: denies itching
• Gynecological: Denies discharge, bleeding, pelvic cramping, leaking of fluids; denies

Braxton Hicks
• Heme/Lymph/Endo: denies heat/cold intolerance

Objective:

Vital signs: B/P: 118/78; HR: 68; T: 98.7 F; RR: 18

Pain: 0/10

Pre-pregnancy weight: 120 lb; Height: 65 inches; BMI: 20.0

Current weight 145 lbs

Pregnancy gain: + 5 lbs in 4 weeks

One hour glucose test result: 156 mg/dL. Positive result

POCT: Urine dipstick: (-) protein

Physical exam:

• Generalized: age appropriate, well developed, well-nourished, no acute distress
• Neurological: alert and oriented
• Cardiology: no swelling noted to BLE, no murmur
• Pulmonary: regular respiratory rate; chest symmetric, no wheezing
• Gastrointestinal: abdomen round; non-tender
• Musculoskeletal: upper and lower extremities, full range of motion; stable gait
• Integumentary: warm and dry
• Psychiatric: calm and cooperative
• Genitourinary: urine clear, no odor
• Gynecological: no vaginal redness or discharge noted
• Fundal height: 25cm (acceptable 22-26 cm)

OB Abdominal ultrasound:

• Intrauterine pregnancy singleton
• Presentation: Vertex
• Fetal cardiac activity present; HR 144
• Amniotic fluid appears adequate
• Fetal movements: Yes
• Fetal breathing movements: Yes

Differential Diagnosis

(1) Urinary tract infection:

• Positives: frequency, urgency, pregnancy
• Negatives: urine clear, no odor, no fevers/chills, no low abdominal/back pain

Final Diagnosis

(1) Gestational diabetes (GD):

• Positives: maternal age > 25, weight gain +5 lbs in 4 weeks, 1-hr glucose teat 156, fatigue,
increased thirst, increased urinary frequency and urgency

Plan:

Diagnostic testing

• Urine POCT in office: to r/o UTI: negative for nitrite and/or leukocyte
• NST: monitors fetal heart rate in response to their movement
• CBC: monitor WBC & platelets, can increase with GD.
• 3-hour 100-g OGTT Glucose challenge: to diagnose GD

Medications:

Continue: Prenatal vitamin: Take 1 tablet by mouth daily.

Vaccine: Tdap

Education:

• Normal weight pre-pregnancy: weight gain 1 lb /week during 2nd – 3rd trimester.
• Complications of GDM if noncompliant
o Maternal: Risk of high blood pressure, preeclampsia, pre-term labor, spontaneous abortion
o Fetus: microsomia, macrosomia (makes delivery difficult), still birth
o Newborn: elevated bilirubin causes jaundice, hypocalcemia, polycythemia, hypoglycemia
• Exercise 30 minutes daily 5 times a week, such as walking
• Limit carbohydrates
• Eat 3 meals and 2 snacks
• Monitor blood glucose at home 4-6 times per day: before meals, and 2 hours after
• 3-hour 100-g OGTT: in the morning after fasting overnight
• Management for Class GDMA1:
o diet, exercise, blood glucose monitoring
• Management for Class GDMA2
o Starting with Metformin 500mg by mouth once a day for one week, then increase to 500 mg

to twice a day to decrease side effects
o Can increase 500 mg every week to a maximum of 2500 ng
o Most common side effects of Metformin: abdominal pain & diarrhea
• Insulin
o Recommended for BMI > 40

o Serious risk factor is hypoglycemia which can lead to coma or death if not treated
immediately

o Symptoms of hypoglycemia: shaking, sweating, agitation, rapid heart rate, clammy skin
o Blood glucose < 80 should be treated with 15 gm of glucose
• Monitor for type DM and insulin resistance after delivery

Referral/Follow-up

• Referral to dietician or diabetes educator- if positive
• Week 28 visit:
o NST:
o Urogynecology for pelvic floor evaluation, exercises
o Transabdominal ultrasound
o Amniotic fluid index (AFI)
o POCT: urine dipstick
• RSV: recommended at 28 weeks to protect the infant from RSV
• Tdap: recommended between 27-36 weeks to protect against pertussis (whooping cough)

Health Maintenance:

• Vision exams: every 2 years- 2026
• Dental exams/cleaning: 2 per year- 7/2025
• Pap: 33 years old
• Vaccines: 10/2025: annual influenza

November 5, 2026