Carolyn Cross V2VE Case Study SOAP Note and Differential Diagnoses for iHuman Case
Carolyn Cross V2VE Case Study SOAP Note and Differential Diagnoses for iHuman Case
Name: Carolyn Cross
Age: 41 years
Sex: F
Height: 5′ 3″
Weight: 155 pounds (BMI 27.5)
Temperature: 98.4 F (oral) Pulse: 76 bpm – regular
Blood pressure: 134/74 mmHg122/72 upon standing
Respiratory rate: 16 bpm SpO2: 98% on room air Carolyn Cross
Chief complaint: Well-woman evaluation SOAP Note and Differential Diagnoses for iHuman Case.
Use this week’s iHuman case titled “Carolyn Cross V2VE” and create a SOAP note with a treatment plan (located at the bottom of the SOAP note.
Provide a subjective, objective, assessment, and plan (SOAP) note on this patient and your treatment plan using the SOAP note template provided Carolyn Cross V2VE Case Study SOAP Note and Differential Diagnoses for iHuman Case. Remember to keep the patient’s identity private; use the minimal amount of information possible to get the idea across.
Provide a reference for your treatment plan (in APA format). The reference may come from a journal, a book, etc. Cite all sources using APA format.
Include three differential diagnoses and support your diagnoses with supporting literature.
Skin: Warm, dry
Ms. Cross is a healthy 41-year-old G2P2 Hispanic-American female who presents for a well-woman examination. She has no active medical complaints, but is concerned about her risk of breast cancer as both her mother (age 63) and maternal first cousin (age 44) have been recently diagnosed with intraductal breast cancer.
Additional risk factors include menarche age 10.5; first pregnancy age 33; she breast fed each of her two infants for only four months each. The patient, reports a normal baseline mammogram at age 40, (report not available) and a history of fibrocystic breast disease. She is overweight (BMI 27.5) with a FH of hypertension, hyperlipidemia (father) and type 2 diabetes (mother).
She is concerned about her risk for breast cancer and does this fact increase her risk of breast cancer, her mother at 63 years old and first cousin 44 year old was recently diagnosed with breast cancer. She performs self-breast examines, no lumps or bumps or discharged noted by patient. She reports breast tenderness around her menstrual cycle.
Denies any health problems past or present. Immunizations are up to date. She gardens and does house work for exercise Carolyn Cross V2VE Case Study SOAP Note and Differential Diagnoses for iHuman Case. She reports later she takes vitamin E for fibro cystic breast disease, she had a mammogram 18 months ago.
Father has hyperlipidemia and HTN and mother is a type 2 DM and just diagnosed at 63 with breast cancer. Pt has a glass of wine every night with supper her diet is traditional Hispanic diet. Both breast is irregular lump and bump bilateral with slight diffuse tenderness. She has two boys and a husband no reported siblings
Labs
- Name
- Value
- Units
- Reference
- Range
- Cholesterol
239 mg/dL low risk <200, moderate 200-239, high >239 High-density lipoprotein (HDL) 45 mg/dL maj risk <40, neg risk >59 Low-density lipoprotein (LDL) 159 units/L low risk <130, moderate 130-159, high >159 Triglycerides 40 mg/dL (?) 35-135, (?) 40-16 Name Value Units Reference Range Glucose, 8 hour fasting 122 mg/dL <126 Name Value Units Reference Range Hemoglobin A1c 6.4 % normal 4-5.6, elevated risk 5.7-6.4, diabetes >6.7 Her papsmear was normal.
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ADDITIONAL INSTRUCTIONS FOR THE CLASS
Discussion Questions (DQ)
Initial responses to the DQ should address all components of the questions asked, include a minimum of one scholarly source, and be at least 250 words.
Successful responses are substantive (i.e., add something new to the discussion, engage others in the discussion, well-developed idea) and include at least one scholarly source.
One or two sentence responses, simple statements of agreement or “good post,” and responses that are off-topic will not count as substantive. Substantive responses should be at least 150 words.
I encourage you to incorporate the readings from the week (as applicable) into your responses.
Weekly Participation
Your initial responses to the mandatory DQ do not count toward participation and are graded separately.
In addition to the DQ responses, you must post at least one reply to peers (or me) on three separate days, for a total of three replies.
Participation posts do not require a scholarly source/citation (unless you cite someone else’s work).
Part of your weekly participation includes viewing the weekly announcement and attesting to watching it in the comments. These announcements are made to ensure you understand everything that is due during the week.
APA Format and Writing Quality
Familiarize yourself with APA format and practice using it correctly. It is used for most writing assignments for your degree. Visit the Writing Center in the Student Success Center, under the Resources tab in LoudCloud for APA paper templates, citation examples, tips, etc. Points will be deducted for poor use of APA format or absence of APA format (if required).
Cite all sources of information! When in doubt, cite the source. Paraphrasing also requires a citation.
I highly recommend using the APA Publication Manual, 6th edition.
Use of Direct Quotes
I discourage overutilization of direct quotes in DQs and assignments at the Masters’ level and deduct points accordingly.
As Masters’ level students, it is important that you be able to critically analyze and interpret information from journal articles and other resources. Simply restating someone else’s words does not demonstrate an understanding of the content or critical analysis of the content.
It is best to paraphrase content and cite your source.
LopesWrite Policy
For assignments that need to be submitted to LopesWrite, please be sure you have received your report and Similarity Index (SI) percentage BEFORE you do a “final submit” to me.
Once you have received your report, please review it. This report will show you grammatical, punctuation, and spelling errors that can easily be fixed. Take the extra few minutes to review instead of getting counted off for these mistakes.
Review your similarities. Did you forget to cite something? Did you not paraphrase well enough? Is your paper made up of someone else’s thoughts more than your own?
Visit the Writing Center in the Student Success Center, under the Resources tab in LoudCloud for tips on improving your paper and SI score.
Late Policy
The university’s policy on late assignments is 10% penalty PER DAY LATE. This also applies to late DQ replies.
Please communicate with me if you anticipate having to submit an assignment late. I am happy to be flexible, with advance notice. We may be able to work out an extension based on extenuating circumstances.
If you do not communicate with me before submitting an assignment late, the GCU late policy will be in effect.
I do not accept assignments that are two or more weeks late unless we have worked out an extension.
As per policy, no assignments are accepted after the last day of class. Any assignment submitted after midnight on the last day of class will not be accepted for grading.
Communication
Communication is so very important. There are multiple ways to communicate with me:
Questions to Instructor Forum: This is a great place to ask course content or assignment questions. If you have a question, there is a good chance one of your peers does as well. This is a public forum for the class.
Individual Forum: This is a private forum to ask me questions or send me messages. This will be checked at least once every 24 hours.