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Directions: Read over the SOAP note and formulate a primary diagnosis. Based on the diagnosis complete the SOAP note with the details that would be expected for the diagnosis. Use UptoDate and/or Dyna MedPlus to find out what is expected from the history and physical, diagnostic workup and management for the diagnosis. Include other peer review resources and and journal articles to support the development of your SOAP note. Complete and attach the evaluation & management score sheet to show how you coded the note for billing in each section.

Case Study: A 47-year-old African-American man presents to your office for a follow-up visit. He was seen 3 weeks ago for an upper respiratory infection and noted incidentally to have a blood pressure of 164/98 mm Hg. He vaguely remembered being told in the past that his blood pressure was “borderline.” He feels fine, has no complaints, and his review of systems is entirely negative. He does not smoke cigarettes, drinks “a couple of beers on the weekends,” and does not exercise regularly. He has a sedentary job. His father died of a stroke at the age of 69. His mother is alive and in good health at the age of 72. He has two siblings and is not aware of any chronic medical issues that they have. In the office today, his blood pressure is 156/96 mm Hg in his left arm and 152/98 mm Hg in the right arm. He is afebrile, his pulse is 78 beats/min, respiratory rate 14 breaths/min, he is 70-in tall, and weighs 210 lb. A general physical examination is normal.

Choose one of the shared theories presented in McEwen & Willis Chapters 13-18, or identify another from the current nursing literature for review in nursing research. (Note: if you select a theory not discussed in the text, please check with your grading faculty).
Access CINAHL and identify two nursing research studies that used the theory in their work (maybe as a conceptual framework, but maybe testing the theory). Be aware that since these are non-nursing theories, much of the research that uses them is from other disciplines. For this assignment, we are interested in how nursing researchers use them (i.e. select nursing journals).
Create an annotated bibliography (if you are unfamiliar with this term, please look it up and an example is also provided here). Focus your notation on how the theory was used for the study – not the process, methods, or findings of the study!!!!
Create a reference list and title page (APA)

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NGR6002c Advance Health Assessment

Nursing homework

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Nursing HOMEWORK

annotated bibliography

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