Focus SOAP Note

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Student Name

Course

Institution Affiliation

Instructor

April 4th, 2023

 

 

Focus SOAP Note

Patient Verification

Name: K.T.

DOB: November 29th, 2013

Minor: Yes

Accompanied by: Mother

Demographic: 9-year-old African American

Gender Identifier Note: Female

SUBJECTIVE:

CC: “I’m depressed.”

HPI:

A 9-year-old African American female presented at the clinic accompanied by her mother. The patient states she feels depressed. The mother also states that the patient has been complaining of feeling depressed. The mother reports that the patient was diagnosed with ADHD in 2020 at the age of 7 years. The mother is away most of the time because of her job. Her sister is also away while at home with her brothers, whom she claims are mean to her most of the time. The patient states she felt lonely because she has no one to play with or talk to. She has five friends in school who are foreigners from different countries. The patient states she does not want to go to school and does not feel like getting up in the morning to go to school. The mother reports the patient is always crying, and she does not want it to get worse, hence the reason they came for evaluation. The patient struggles in school, especially in math, with low grades. However, she is respectful in class, and she loves art and writing, drawing, painting, and sketching but finds it very hard to learn new subjects. She has problems with concentration. Painting and sketches make her less sad. The patient reports that she does not express her feelings in school but in her head. The mother reports patient has problems sleeping and decreased appetite. The client denies suicidal and homicidal thoughts and intent to hurt others. However, she has sometimes made her lips bleed twice and slapped herself on the wrist.

Social Hx: Mother, 38 years, has a history of bipolar 1 disorder with borderline traits and PTSD. Patient has 3 siblings, two brothers, and one sister. Sister has a history of anxiety and is not around most of the time. Mother is also not around, mostly due to her job. Parents are divorced, and the dad, 41, has no visitation right or custody.

Legal Hx: Denied.

Medical Hx: Denied.

Surgical Hx: Denied

Psychiatric Hx: Patient has a history of ADHD. The mother has a history of bipolar 1 disorder with borderline traits and PTSD. Sister has a history of anxiety

Psychiatric medication use: Denied.

Substance Abuse History: Denied.

ROS:

General: Denies weight loss, fever, chills, weakness, or fatigue.

HEENT: Eyes: denies visual loss, blurred vision, double vision, or yellow sclerae. Ears, Nose, Throat: No hearing loss, sneezing, congestion, runny nose, or sore throat.

Skin: No rash or itching.

Cardiovascular: Denies chest pain, chest pressure, or chest discomfort. No palpitations or edema.

Respiratory: Denies wheezes, shortness of breath, consistent coughs, and breathing difficulties while resting.

Gastrointestinal: No anorexia, nausea, vomiting, or diarrhea. No abdominal pain or blood. Reports decreased appetite.

Genitourinary: Denies burning on urination, urgency, hesitancy, odor, odd color

Neurological: Denies headache, dizziness, syncope, paralysis, ataxia, numbness, or tingling in the extremities. No change in bowel or bladder control. Reports difficulties were concentrating and paying attention.

Musculoskeletal: Denies muscle, back pain, joint pain, or stiffness.

Hematologic: Denies anemia, bleeding, or bruising.

Lymphatics: Denies enlarged nodes. No history of splenectomy.

Endocrinologic: Denies sweating, No reports of cold or heat intolerance. No polyuria or polydipsia.

OBJECTIVE

Vital Signs

Temp: 98.3 F

B.P.: 117/59

HR:71

R: 18; non-labored

O2: 96% room air

Pain: Negative

Ht:4ft, 7 inches

Wt.: 71.2 lbs.

BMI:17.9

BMI Range: Healthy Weight

Physical Exam: General appearance: The patient appears healthy and well-fed. She routinely discusses with the medical personnel; however, she easily gets distracted and abruptly leaves the subject under discussion. The mother steps in to assist with replying.

HEENT: Normocephalic and atraumatic. Sclera anicteric, No conjunctival erythema, PERRLA, oropharynx red, moist mucous membranes.

Neck: Supple. No JVD. Trachea midline. No pain, swelling, or palpable nodules.

Heart/Peripheral Vascular: Regular rate and rhythm noted. No murmurs. No palpitation. No peripheral edema to palpation bilaterally.

Cardiovascular: Although the patient’s heartbeat and rhythm are regular, murmurs and other sounds are coming from her chest. The patient’s heart rate is constant, and capillaries refill in two seconds.

Musculoskeletal: Normal range of motion. Regular muscle mass for age. No signs of swelling or joint deformities.

Respiratory: No wheezes, and respirations are easy and regular.

Neurological: Balance is stable, gait is normal, posture is erect, the tone is good, and speech is clear.

Psychiatric: The patient’s fast switching from one discussion or topic to another indicates inattentiveness. Patient is easily distracted yet occasionally appears to pay attention to the mother and the practitioner.

Neuropsychological testing: Patient has difficulties executing functions where he is required to prioritize, plan, inhibit behavior, and attend to processing speed, especially schoolwork.

ASSESSMENT

MSE: K.T. underwent a mental health assessment. The patient has dressed appropriately for the setting and the season. Despite being highly talkative, she remained seated during the interview, was compliant, and displayed no discomfort. The patient denied having hallucinations, suicidal or homicidal thoughts, paranoia, insomnia, appetite loss, or auditory or visual hallucinations.

DSM5 Diagnosis

  1. F90.9. Attention-Deficit hyperactivity disorder (Confirmed):

Attention-deficit/hyperactivity disorder (ADHD), a chronic mental health condition that frequently worsens as people age, affects millions of children. ADHD’s enduring symptoms include hyperactivity, impulsive behavior, and difficulties paying focus. For those with ADHD, especially children, common issues include low self-esteem, troubled relationships, and lack of involvement (Magnus et al., 2017). Impulsivity, disorganization, poor time management, difficulty setting priorities, difficulty focusing, difficulties multitasking, excessive activity and restlessness, poor planning, and a low threshold for irritability are some symptoms of ADHD.

The patient reported experiencing depressive, lonesome, and melancholy feelings, typical of many ADHD patients. The DSM-5 diagnostic criteria for people with ADHD include five or more inattention symptoms, several of which must have appeared before the age of 12, several of which must have appeared in two settings, evidence that the symptoms impair or negatively affect social or academic functioning, and symptoms that do not only coexist with another psychotic disorder (Magnus et al., 2017). The patient demonstrates continuous loss of focus and attention and has previously been diagnosed with ADHD. The patient claims to be depressed and exhibits many symptoms of depression. However, ADHD patients also report decreased appetite, symptoms resembling sleep deprivation, and are more likely to engage in non-suicidal and suicidal self-harm, which may account for the patient’s bleeding lips and slapping of oneself. The primary diagnosis, according to the examination, is ADHD.

  1. F32.9 Major Depressive Disorder

A prolonged sense of sadness and passivity are two features of depression. All depressive disorders have the symptoms of sadness, emptiness, or irritability, as well as other physical and mental changes that significantly restrict the patient’s capacity to function (Chand et al., 2021). Patients who are depressed have noticeably lower interest in or excitement for nearly all endeavors for the majority of the day, essentially every day. According to the DMS-5 criteria, a diagnosis requires five of the following symptoms: trouble sleeping, loss of intrigue or pleasure, feelings of inadequacy or helplessness, fatigue or erratic energy, problems concentrating or listening attentively, fluctuations in appetite or weight, psychomotor issues, suicidality, and depressed mood (Agostino et al., 2021). The patient claims to feel down, melancholy, and lonely. Moreover, the patient has trouble falling asleep and has less desire to eat. The patient disputes any suicidal thoughts. Many depressive symptoms are present in the patient; however, the diagnosis was ruled out because the patient did not exhibit a protracted state of sadness.

  1. F41.9. Generalized Anxiety Disorder

Excessive, exaggerated anxiety and worry about everyday events without an apparent reason are characteristics of a generalized anxiety disorder (GAD) (Munir et al., 2021). 3.1% of the population, or more than 6.8 million people, are affected. Although it can begin at any age and progress gradually, the risk is most between the ages of five and middle age. Biological variables, family history, life events, and other stressors contribute to GAD, despite the exact cause being unknown (Toussaint et al., 2020). Looking for symptoms like excessive, persistent worry and tension, unrealistic views of problems, restlessness or a feeling of being “edgy,” difficulty focusing, quickly becoming exhausted, increased crankiness or irritability, trouble sleeping, and muscle tension can help diagnose a general anxiety disorder. Individuals with GAD frequently see doom coming and worry excessively about everyday occurrences like going to work. GAD is diagnosed when a person has uncontrollable worrying, which K.T. does not have.

PLAN

Pharmacologic interventions:

  • Start Venlafaxine 18.75-75 mg/day; may increase to 150 mg/day after 4 weeks

Psychotherapy

Behavioral psychotherapy: With behavioral therapy and the appropriate medication, it can improve ADHD symptoms while enhancing executive function, lowering anxiety, and reducing hyperactivity (Magnus et al., 2017).

Psychosocial interventions: Psychosocial therapies, including applied relaxation interpersonal psychotherapy, short-term psychodynamic psychotherapy, and social skills instruction, can assist in lessening the symptoms of ADHD and anxiety (Magnus et al., 2017).

Cognitive therapy: Cognitive-behavioral therapy helps reduce anxiety and restlessness sensations that arise when performing tasks, improve focus and time management, and improve mood (Lopez et al., 2018).

 

 

Patient Education

  • Talk to the patient and parent about the risks and benefits of medication, including non-treatment and probable side effects.
  • Discuss with the patient and parent when to stop the medication, how to recognize it, and when to report adverse events.
  • Talk to the patient and parent about the dangers of combining prescription pharmaceuticals with OTC, illicit, or natural substances.
  • Educate patient and parent to develop structured daily routines and schedules and minimize changes.
  • Engage the patient in skills training.
  • Encourage patient and parent to make time for exercise every day.
  • Educate the patient to accept herself and her limitations and interact with people who accept her.
  • Teach patients to create a system for prioritizing the day and create deadlines for activities.
  • Advise parents to create more time to spend with the patient.

Follow-up: Patient should follow up after one week for psychotherapy.

Reflection

Access to treatment in mental health, and in particular ADHD, has not been actualized fully because, by 2017, only 75.2% of children had received treatment per the Healthy People 2030, implying a significant part of the population, about 25%, have not received treatment. Based on the most recent data (2020-2021), only 72.5% had received treatment. Healthy People 2030 targets this proportion to reach 79.4% (Healthy People 2030). The goal is to increase the number of children and adolescents with ADHD who access developmentally appropriate treatment like behavioral therapy and/or medication. This initiative would help more patients enhance their health outcomes and integrate and function normally in society. Regarding health promotion, ADHD patients are at an increased risk of being overweight and developing obesity. Recommending and guiding healthy habits like healthy diets, including vegetables, fruits and whole grains, frequent physical activity, and reducing screen time would be appropriate in preventing weight-related health issues.

If I was to conduct the session over; I would contact the teacher and the family physician to gather more information and perspectives that the child or the parent might have missed out or not disclosed. Teachers spend more time with the child and hence have more understanding and knowledge regarding the challenges the child faces in class and socializing with others. The family physician is highly knowledgeable of the deficiencies in functioning or issues the child experiences. I followed up with the patient, and the interventions had achieved the expected objectives, but it is still a work in progress. Addressing ADHD can take time because it is a learning process involving comprehensive training and coaching of the child and the patient to ensure optimal results.

References

Chand, S. P., Arif, H., & Kutlenios, R. M. (2021). Depression (Nursing). In: StatPearls [Internet]. StatPearls Publishing.

Healthy People 2030. (n.d.). Increase the proportion of children and adolescents with ADHD who get appropriate treatment — EMC‑04. https://health.gov/healthypeople/objectives-and-data/browse-objectives/children/increase-proportion-children-and-adolescents-adhd-who-get-appropriate-treatment-emc-04

Lopez, P. L., Torrente, F. M., Ciapponi, A., Lischinsky, A. G., Cetkovich-Bakmas, M., Rojas, J. I., Romano, M., & Manes, F. F. (2018). Cognitive-behavioral interventions for attention deficit hyperactivity disorder (ADHD) in adults. The Cochrane Database of systematic reviews, 3(3), CD010840. https://doi.org/10.1002/14651858.CD010840.pub2

Magnus, W., Nazir, S., Anilkumar, A. C., & Shaban, K. (2017). Attention deficit hyperactivity disorder (ADHD).

Munir, S., Takov, V., & Coletti, V. A. (2021). Generalized Anxiety Disorder (Nursing). StatPearls [Internet].

Toussaint, A., Hüsing, P., Gumz, A., Wingenfeld, K., Härter, M., Schramm, E., & Löwe, B. (2020). Sensitivity to change and minimal clinically important difference of the 7-item Generalized Anxiety Disorder Questionnaire (GAD-7). Journal of affective disorders, 265, 395-401

 
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Nursing Paper Example on Amyloidosis

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Nursing Paper Example on Amyloidosis

Amyloidosis is a rare and complex group of diseases characterized by the accumulation of amyloid, an abnormal protein, in various tissues and organs throughout the body. The amyloid deposits can interfere with the normal functioning of organs, leading to serious health complications. The condition can affect any organ, though the heart, kidneys, liver, and nervous system are most commonly involved. Due to its varied manifestations and challenges in diagnosis, amyloidosis requires careful management and treatment.

Nursing Paper Example on Amyloidosis

Causes of Amyloidosis

Amyloidosis is caused by the deposition of amyloid fibrils, which are abnormal aggregates of protein that accumulate in tissues and organs. These fibrils are formed when proteins misfold and aggregate, leading to damage to normal cellular structures. There are several types of amyloidosis, and the causes vary according to the type:

  • Primary (AL) amyloidosis: This form is the most common and occurs when abnormal plasma cells in the bone marrow produce excessive amounts of light chain proteins, which misfold and form amyloid deposits. It is typically associated with monoclonal gammopathy.
  • Secondary (AA) amyloidosis: This form occurs as a complication of chronic inflammatory diseases, such as rheumatoid arthritis, inflammatory bowel disease, or chronic infections. In this case, the protein amyloid A (AA) is produced in excess and deposited in tissues.
  • Hereditary (Familial) amyloidosis: Inherited mutations in certain genes, such as the transthyretin (TTR) gene, lead to the production of abnormal proteins that misfold and form amyloid deposits. Familial amyloidosis can affect multiple organs, particularly the heart and nervous system.
  • Dialysis-related amyloidosis: This form occurs in patients on long-term dialysis, where the β2-microglobulin protein accumulates and forms amyloid deposits in joints and bones.
  • Wild-type transthyretin amyloidosis (ATTRwt): In this type, wild-type transthyretin proteins, which are usually found in normal conditions, misfold and accumulate in tissues, most notably in the heart.

Signs and Symptoms

The clinical manifestations of amyloidosis are highly dependent on the organs involved and the extent of amyloid deposition. The signs and symptoms can be subtle at first and often mimic other diseases, making diagnosis challenging. Common manifestations include:

  • Cardiac involvement:
    • Heart failure: Amyloid deposits in the heart can impair its function, leading to restrictive cardiomyopathy, which manifests as heart failure with preserved ejection fraction (HFpEF). Symptoms may include shortness of breath, fatigue, and fluid retention.
    • Arrhythmias: Amyloidosis can cause irregular heartbeats, leading to symptoms such as palpitations or dizziness.
  • Renal involvement:
    • Proteinuria: The deposition of amyloid in the kidneys can cause damage to the glomeruli, leading to leakage of protein into the urine.
    • Nephrotic syndrome: In more severe cases, patients may experience swelling, particularly in the legs, and a significant reduction in kidney function.
  • Neurological involvement:
    • Peripheral neuropathy: Amyloid deposits can affect peripheral nerves, leading to symptoms such as numbness, tingling, and pain in the hands and feet. Autonomic neuropathy, which affects involuntary functions like blood pressure regulation and digestion, is also common.
    • Carpal tunnel syndrome: One of the early signs of amyloidosis, carpal tunnel syndrome, results from amyloid deposits around the wrist, causing compression of the median nerve.
  • Gastrointestinal involvement:
    • Malabsorption: Amyloid deposits in the gastrointestinal tract can interfere with nutrient absorption, leading to diarrhea, weight loss, and bloating.
    • Hepatomegaly: Liver enlargement is often seen in cases of secondary amyloidosis due to the accumulation of amyloid in the liver.
  • Other manifestations:
    • Skin changes: In some cases, amyloid deposits in the skin can cause purpura, easy bruising, and a waxy appearance to the skin.
    • Enlarged tongue: In rare cases, amyloid deposits in the tongue can cause it to become enlarged and cause difficulty with speech and swallowing.

Etiology of Amyloidosis

Amyloidosis occurs when specific precursor proteins misfold and aggregate into amyloid fibrils, which deposit in tissues and organs. These fibrils are composed of protein subunits, but the exact cause of protein misfolding can vary depending on the type of amyloidosis:

  • Primary (AL) amyloidosis: Caused by the overproduction of light chains (immunoglobulin fragments) by monoclonal plasma cells in the bone marrow. These light chains misfold and form amyloid fibrils that deposit in organs.
  • Secondary (AA) amyloidosis: Resulting from chronic inflammation or infection, the liver produces excess amyloid A protein, which is prone to forming amyloid fibrils. Chronic conditions like rheumatoid arthritis or inflammatory bowel disease can trigger the overproduction of amyloid A.
  • Hereditary amyloidosis: Genetic mutations in proteins like transthyretin (TTR) lead to misfolding and the formation of amyloid fibrils. Inherited forms are typically passed down in an autosomal dominant manner.
  • Dialysis-related amyloidosis: The accumulation of β2-microglobulin, a protein that is usually cleared by the kidneys, leads to amyloid deposition in patients on long-term dialysis.

Pathophysiology of Amyloidosis

The hallmark of amyloidosis is the deposition of amyloid fibrils in tissues, where they interfere with normal cellular and organ function. The misfolded proteins form insoluble aggregates, which are deposited extracellularly. The accumulation of amyloid fibrils disrupts the structure and function of affected organs, leading to organ dysfunction. The pathophysiological effects depend on the organs involved:

  • Kidneys: Amyloid fibrils deposited in the glomeruli lead to nephrotic syndrome, which is characterized by proteinuria, edema, and hypoalbuminemia.
  • Heart: Amyloid deposits in the myocardium cause restrictive cardiomyopathy, where the heart becomes stiff and less able to expand, leading to heart failure.
  • Nervous system: Amyloid fibrils deposited in peripheral nerves lead to neuropathy, which can cause sensory and motor deficits, as well as autonomic dysfunction.
  • Liver and spleen: Amyloid deposits in these organs can lead to hepatomegaly and splenomegaly, causing discomfort and dysfunction.

DSM-5 Diagnosis

Amyloidosis is not classified as a psychiatric disorder and, as such, is not included in the DSM-5. The diagnosis of amyloidosis is primarily based on clinical features, histopathology, and laboratory testing. A definitive diagnosis requires the identification of amyloid deposits in tissue, which can be done through:

  1. Tissue biopsy: A biopsy of the affected organ, often the abdominal fat pad or rectum, can reveal amyloid deposits under light microscopy. Congo red staining of tissue samples is commonly used to detect amyloid deposits, as amyloid fibrils stain bright red under polarized light.
  2. Serum protein electrophoresis (SPEP): This test can help detect abnormal monoclonal proteins in cases of AL amyloidosis.
  3. Immunohistochemistry: Immunohistochemistry can identify the specific type of amyloid protein (e.g., AA, AL, TTR).
  4. Genetic testing: In cases of suspected hereditary amyloidosis, genetic testing may be performed to identify mutations in the TTR gene or other relevant genes.

Treatment Regimens

The treatment of amyloidosis depends on the type of amyloidosis, the organs involved, and the stage of disease. Treatment generally aims to reduce amyloid production, manage organ dysfunction, and improve quality of life:

  1. Primary (AL) amyloidosis:
    • Chemotherapy: As AL amyloidosis is associated with plasma cell dyscrasia, chemotherapy is often used to reduce the production of the abnormal light chains. Common drugs include melphalan and cyclophosphamide.
    • Stem cell transplantation: In selected patients, autologous stem cell transplantation may be used to treat AL amyloidosis by eliminating the malignant plasma cells producing amyloid.
  2. Secondary (AA) amyloidosis:
    • Treating the underlying cause: The primary treatment for AA amyloidosis is controlling the underlying chronic inflammatory condition, such as rheumatoid arthritis, using anti-inflammatory drugs like colchicine or biologics like TNF inhibitors.
  3. Hereditary amyloidosis:
    • TTR stabilization: In hereditary transthyretin amyloidosis (ATTR), treatments that stabilize the transthyretin protein, such as tafamidis, can prevent amyloid formation.
    • Liver transplantation: In severe cases, liver transplantation may be necessary, as the liver produces the defective transthyretin protein.
  4. Dialysis-related amyloidosis:
    • Dialysis modification: Newer dialysis techniques that more effectively remove β2-microglobulin may help prevent further amyloid accumulation.
    • Joint replacement surgery: For patients with severe joint involvement, joint replacement may be necessary.

Patient Education

Patient education is essential in managing amyloidosis. Key areas of education include:

  1. Disease awareness: Patients need to understand the nature of amyloidosis, the organs involved, and the potential symptoms to watch for.
  2. Lifestyle modifications: Patients should be advised on managing symptoms such as fluid retention, managing diet, and avoiding stress.
  3. Treatment adherence: Patients should be educated on the importance of adhering to prescribed medications, including chemotherapy and immunosuppressive agents, if applicable.
  4. Regular monitoring: Ongoing monitoring of organ function is critical to detect any progression of the disease.

Conclusion

Amyloidosis is a rare but serious condition that can lead to significant organ dysfunction if not diagnosed and treated appropriately. Understanding the causes, symptoms, and treatment options is essential for effective management. Early diagnosis and timely intervention can improve patient outcomes and quality of life.

References

Gillmore, J. D., Gertz, M. A., & Merlini, G. (2021). Amyloidosis: Pathophysiology, diagnosis, and management. The Lancet, 398(10301), 447-459. https://doi.org/10.1016/S0140-6736(21)00746-2

Dispenzieri, A., & Gertz, M. A. (2020). Amyloidosis: Diagnosis and treatment. Current Hematologic Malignancy Reports, 15(5), 337-347. https://doi.org/10.1007/s11899-020-00606-5

Kyle, R. A., & Rajkumar, S. V. (2019). Amyloidosis: Pathophysiology and treatment. Blood Reviews, 38, 100637. https://doi.org/10.1016/j.blre.2019.100637

 
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Nursing Paper Example on Psoriasis

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Nursing Paper Example on Psoriasis

Psoriasis is a chronic autoimmune disease characterized by the rapid growth of skin cells, leading to thick, scaly patches on the skin. Affecting approximately 2–3% of the global population, psoriasis is both physically and psychologically burdensome. The condition can manifest at any age, though it most commonly develops between the ages of 15 and 35. While the exact cause of psoriasis remains unknown, a combination of genetic, environmental, and immune factors contribute to its development. Psoriasis is not just a cosmetic condition but also a systemic disease that can affect various aspects of an individual’s health, especially when associated with complications like psoriatic arthritis.

Causes and Risk Factors

Psoriasis arises from a complex interplay of genetic predisposition and environmental triggers. Genetics play a significant role, as individuals with a family history of the disease are more likely to develop it. The immune system is central to psoriasis, where overactive T-cells (a type of white blood cell) mistakenly attack healthy skin cells, causing an accelerated production of skin cells. Environmental factors such as stress, infections, and skin trauma (known as the Koebner phenomenon) can trigger or exacerbate psoriasis. Moreover, lifestyle factors like obesity, smoking, and alcohol consumption are associated with an increased risk of developing or worsening the disease.

Types of Psoriasis

Psoriasis manifests in several forms, each with distinct characteristics:

  1. Plaque Psoriasis (Psoriasis Vulgaris): The most common type, plaque psoriasis presents as raised, red patches covered with silvery-white scales.
  2. Guttate Psoriasis: This type often appears suddenly and is typically triggered by a bacterial infection like strep throat, presenting as small, drop-shaped lesions.
  3. Inverse Psoriasis: Found in skin folds such as the armpits and groin, inverse psoriasis appears as smooth, red patches of skin.
  4. Pustular Psoriasis: This severe form causes pus-filled blisters surrounded by red skin, typically affecting the hands and feet.
  5. Erythrodermic Psoriasis: A rare, life-threatening form of psoriasis characterized by widespread inflammation, redness, and skin shedding.
  6. Nail Psoriasis: Affects nails, causing pitting, discoloration, and abnormal nail growth.

Signs and Symptoms

The primary symptom of psoriasis is the formation of thick, scaly plaques on the skin, which can be itchy and painful. These plaques may vary in size and typically develop on the scalp, elbows, knees, and lower back. Additional symptoms include dry and cracked skin that may bleed, nail abnormalities (e.g., pitting and discoloration), and joint pain in cases of psoriatic arthritis. Psoriasis is a cyclic condition, with periods of flare-ups and remission. Beyond its physical symptoms, psoriasis can also have profound emotional effects, leading to anxiety, depression, and social isolation due to the visible nature of the lesions.

Etiology

Psoriasis is an autoimmune disorder in which the body’s immune system mistakenly identifies healthy skin cells as a threat, triggering an abnormal response. The immune system accelerates the life cycle of skin cells, causing them to multiply rapidly and accumulate on the skin’s surface. While the exact cause is not fully understood, genetic factors are believed to contribute significantly. Over 40% of individuals with psoriasis have a family history of the disease. Additionally, certain genes, particularly those associated with the immune system (e.g., HLA-Cw6), are linked to psoriasis development. Environmental triggers such as infections, certain medications (e.g., beta-blockers), and physical or emotional stress can also play a key role in the onset or exacerbation of psoriasis.

Pathophysiology

The pathophysiology of psoriasis involves an abnormal immune response that results in the overproduction of skin cells. T-cells, a type of white blood cell, become overactive and release pro-inflammatory cytokines such as tumor necrosis factor-alpha (TNF-α), interleukin-17 (IL-17), and interleukin-23 (IL-23). These cytokines trigger the rapid production of keratinocytes (skin cells) in the epidermis. Instead of the normal 28-day turnover cycle, skin cells in psoriatic lesions regenerate every 3–4 days. This rapid turnover leads to the accumulation of dead skin cells on the surface, resulting in the characteristic plaques. Chronic inflammation also plays a key role in joint damage in patients with psoriatic arthritis.

Diagnosis

Psoriasis is typically diagnosed through a physical examination of the skin, scalp, and nails. In most cases, a clinical diagnosis is sufficient, based on the appearance and distribution of lesions. For cases that are not typical, a skin biopsy may be performed to differentiate psoriasis from other skin conditions such as eczema or fungal infections. Additional diagnostic measures, such as blood tests and imaging, are used when psoriatic arthritis is suspected, helping to assess joint involvement and inflammation.

Complications

While psoriasis primarily affects the skin, it can lead to several complications:

  1. Psoriatic Arthritis: Up to 30% of individuals with psoriasis develop psoriatic arthritis, a condition characterized by joint pain, stiffness, and swelling.
  2. Cardiovascular Disease: Chronic inflammation associated with psoriasis increases the risk of heart disease and stroke.
  3. Psychological Impact: The visible nature of psoriasis can significantly impact an individual’s quality of life, leading to mental health conditions such as anxiety and depression.
  4. Metabolic Syndrome: Psoriasis is linked to an increased risk of developing metabolic syndrome, which includes obesity, hypertension, and diabetes.

(Nursing Paper Example on Psoriasis)

Treatment Options

Psoriasis treatment aims to reduce inflammation, control the rapid production of skin cells, and manage symptoms. Treatment options vary depending on the severity of the disease and may include:

  1. Topical Therapies: These include corticosteroids, vitamin D analogs, and coal tar. These medications help reduce inflammation and slow the growth of skin cells.
  2. Phototherapy: Phototherapy involves exposing the skin to ultraviolet (UVB) light to reduce the growth of skin cells. PUVA therapy, which combines psoralen medication with UVA light, is another option for more severe cases.
  3. Systemic Therapies: For moderate to severe psoriasis, systemic medications such as methotrexate, cyclosporine, and retinoids may be used. These medications work throughout the body to suppress the immune response.
  4. Biologic Therapies: Biologics target specific components of the immune system, particularly TNF-α, IL-17, and IL-23. Common biologics include etanercept, adalimumab, and ustekinumab.
  5. Lifestyle and Alternative Therapies: Lifestyle modifications such as smoking cessation, weight management, and regular exercise can help reduce the risk of flare-ups. Alternative therapies like aloe vera and fish oil supplements may provide additional relief for some patients.

Patient Education and Lifestyle Modifications

Educating patients about psoriasis is crucial for managing the condition and improving quality of life. Patients should be informed about the chronic nature of the disease and the importance of adherence to treatment plans. Stress management techniques, such as mindfulness and relaxation exercises, can help reduce flare-ups. Patients should avoid known triggers, including smoking and excessive alcohol consumption. Additionally, regular skin care, including the use of moisturizers and gentle cleansers, is essential for minimizing dryness and irritation.

(Nursing Paper Example on Psoriasis)

Conclusion

Psoriasis is a chronic autoimmune condition with complex causes and multiple manifestations. While there is no cure for psoriasis, treatments ranging from topical medications to biologics can significantly improve the quality of life for individuals affected by this condition. Early diagnosis, patient education, and a personalized treatment plan are essential for effectively managing psoriasis and its associated complications, including psoriatic arthritis and cardiovascular disease.

(Nursing Paper Example on Psoriasis)

References

  1. National Psoriasis Foundation. Psoriasis Overview. https://www.psoriasis.org/about-psoriasis
  2. Mayo Clinic. Psoriasis: Symptoms and Causes. https://www.mayoclinic.org/diseases-conditions/psoriasis/symptoms-causes/syc-20355840
  3. World Health Organization. Global Report on Psoriasis. https://www.who.int/publications/i/item/global-report-on-psoriasis
  4. Armstrong, A. W., & Read, C. (2020). Pathophysiology, Clinical Presentation, and Treatment of Psoriasis. JAMA, 323(19), 1945–1960. https://jamanetwork.com/journals/jama/fullarticle/2767932
  5. Lowes, M. A., Suárez-Fariñas, M., & Krueger, J. G. (2014). Immunology of Psoriasis. Annual Review of Immunology, 32, 227–255. https://www.annualreviews.org/doi/10.1146/annurev-immunol-032713-120225
 
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Skin Comprehensive SOAP Note 

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Skin Comprehensive SOAP Note 

(Skin Comprehensive SOAP Note)

Skin Comprehensive SOAP Note

Patient Initials: D.W.              Age: 32                                   Gender: Female

SUBJECTIVE DATA:

Chief Complaint (CC) (Graphic 2): “I feel less confident around people, including my husband, and I cannot go out to swim or wear bikini or crop tops.”

History of Present Illness (HPI): D.W. is a 32-year-old single African American woman who is 29 weeks pregnant and presenting at the clinic with complaints of increasing stretch marks in the past one and a half months. D.W. claims that due to the stretch marks, she has lost confidence and self-esteem. She denies feeling any pain in places of the abdomen but explains that the area might be “itchy” and that the lines are continuing to darken. She claims that since she cannot wear a bikini, crop top, or swimsuit, she would like anything to reduce the stretch marks. She indicates 0/10 for reported pain on the pain scale and denies fever. Over-the-counter cocoa butter was ineffective in eliminating or reducing stretch marks. She also thinks her stretch marks are related to weight gain. (Week 4 – Skin Comprehensive SOAP Note)

Medications:

  1. Prenatal Rx: 1 tablet daily
  2. Amlodipine for HTN: 10 mg daily
  3. Albuterol 90mcg for Asthma
  4. Cortisone OTC for itching skin: Applies at least 6 times daily

Allergies: Patient reports she is allergic to dust, mold, pollen, and metronidazole

Past Medical History (PMH): The patient developed HTN when she was 24, asthma at 4 years, although controlled, and allergic rhinitis at age 7. She also has past medical history of bacterial vaginosis, controlled with medication, and anxiety, which was managed without medication.

Past Surgical History (PSH): The patient underwent a surgical report of the umbilical hernia in 2006.

Sexual/Reproductive History: D.W. reports that she is married with one child, which she conceived at 26 years. This is her second pregnancy. She is sexually active and not on using condoms. She has one sexual partner, and together they go for regular testing for STIs, every four months.

Personal/Social History: She is married and currently lives with her husband. She has an extended family comprising of her mother and father and two brothers. (Week 4 – Skin Comprehensive SOAP Note)

Health Maintenance:

  • She does not smoke
  • She maintains one sexual partner
  • Maintains a healthy diet, although she has experienced weight gain during pregnancy.
  • She maintains a healthy, supportive relationships with members of the extended family and friends.

Immunization History:

  1. Covid vaccination
  2. Influenza vaccine: 09/10/2019
  3. Tdap: 07/4/2020
  4. Measles and Rubella

Significant Family History: She has an extended family comprising of the mother, father and two brothers. Her grandparents are dead. The mother, 60, has a history of asthma and depression. The father, 63, has a history of diabetes. The brothers are 35 and 27 years and have no medical history.

Review of Systems:

General: The patient reports fatigue over the last two months. She denies fever, syncope, lightheadedness with standing or ambulation, or chills. She reports sleeping 7-10 hours a day. She reports pervasive weight gain over the course of her pregnancy, gaining about 10 pounds. (Week 4 – Skin Comprehensive SOAP Note)

            HEENT

Respiratory: Patient reports a history of asthma. Denies history of pneumonia, dyspnea or hemoptysis. Reports dyspnea during vigorous physical activities like running or walking fast.

Cardiovascular/Peripheral Vascular: Denies chest pain, chest pressure, or chest discomfort. No palpitations or edema.

Gastrointestinal: The patient reports diet changes, feelings of nausea and vomiting. Denies diarrhea. No abdominal pain or blood. Patient reports experiencing constipation.

Genitourinary: Denies burning on urination, urgency, hesitancy, odor, odd color.

Musculoskeletal: The patient reports occasional muscle pain and weakness. Denies back pain and muscle or joint stiffness.

Neurological: Denies headaches, dizziness, syncope, paralysis, ataxia, numbness, or tingling in the extremities. No change in bowel or bladder control.

Psychiatric: Patient reports a history of anxiety, controlled nonmedically through meditation and physical exercise.

Skin/hair/nails: Patient indicates intermittent abdominal pruritus, scalp dandruff. Patient denies dermatitis on other body areas, spontaneous bruising, brittle hair, yellowing nails, or fungal infections. She reports itching, controlled using Cortisone OTC.  

OBJECTIVE DATA:

Physical Exam:

Vital signs: temp: 98.6F, B.P.: 100/65, P: 85, R.R.: 18, pain: 0/10 Ht: 5’5 feet, Wt.: 167 lbs., BMI: 27.8

General: Well-nourished and groomed AXOx4 32-year-old Black female, with appropriate mood, bright affect, and polite.

HEENT: Normocephalic and atraumatic. Sclera anicteric, No conjunctival erythema, PERRLA, oropharynx red, moist mucous membranes.

Neck: Supple. No JVD. Trachea midline. No pain, swelling, or palpable nodules.

Chest/Lungs: The patient’s heartbeat and rhythm are normal. The patient’s heart rate is within normal range, and capillaries refill within two seconds.

Heart/Peripheral Vascular: Regular rate and rhythm noted. No murmurs. No palpitation. No peripheral edema to palpation bilaterally.

Abdomen: Normal active bowel sounds x4. No rebound tenderness X 4. Soft abdomen. No organomegaly. Fundal distance 30cm

Genital/Rectal: D.W. decline, reporting seeing a gynecologist routinely.

Musculoskeletal: Normal range of motion. Low muscle mass for age. No signs of swelling or joint deformities. Muscle and back pain rated 0/10.

Neurological: Balance is stable, gait is normal, posture is erect, the tone is good, and speech is clear.

Skin: Multiple stretch marks visible on the abdomen; color nigrae and albae. Noted skin xerosis to the abdomen, linea nigra vertically from pubic bone to intermediary breast. No lymph nodes on palpation. Severe striae as indicated by TSS:> 18 (Week 4: Skin Comprehensive SOAP Note )

Diagnostic results:

  1. HCT – 36
  2. WBC 5.89
  3. Albumin – 3.7
  4. Sodium – 135
  5. Potassium – 3.7
  6. AIC – 4.6
  7. Fibrinogen – 215
  8. Rh negative

ASSESSMENT:

Primary diagnosis:

  1. Striae gravidarum and Linea Nigra:

Stretch marks, or striae gravidarum, develop in roughly 50 to 90% of pregnant women as the uterus grows inside the abdominal cavity and separates the connective tissue beneath (Oakley & Patel, 2022). Early stretch marks are reddish-purple and develop as skin collagen is damaged and blood vessels enlarge. White or brown mature stretch marks result from melanocytes or pigment-producing cells dying due to collagen remodeling. Stretch marks most frequently appear on the breasts, thighs, and abdomen (Dai et al., 2021). A woman’s skin type and family history affect the thickness of the striae. The weight gain D.W. experienced could explain the striae gravidarum, the first confirmed diagnosis, vividly noticeable to her abdomen.

Linea is a brown line visible on the abdomen, running from the umbilical to the symphysis pubis. Usually, around the second or third trimester of pregnancy, linea nigra symptoms manifest. Linea nigra hyperpigmentation is brought on by hormonal fluctuations in progesterone and estrogen during pregnancy, which lead the cells to stimulate melanocytes in the skin more (Barnawi et al., 2021). The skin’s increased melanocyte count is what makes the abdomen darker. Linea nigra is also vividly noticeable on D.W. abdomen, confirming it as the second diagnosis. (Week 4 – Skin Comprehensive SOAP Note)

Week 4: Skin Comprehensive SOAP Note

Differential Diagnosis

  1. Linear Focal Elastosis: Uncertain etiology characterizes linear focal elastosis (LFE), an unusual benign acquired elastotic disease. Clinically, it is distinguished by several asymptomatic, raised, yellowish striae-like lines or bands dispersed horizontally throughout the lower and middle portion of the posterior trunk (Florell et al., 2017). The dermis’s focused increase in elastic fibers is the histological sign of LFE. The most common differential for LFE is Striae distensae.

Week 4: Skin Comprehensive SOAP Note

  1. Steroid Induced Skin Atrophy: Topical steroids applied excessively on the skin might lead to steroid-induced skin atrophy. D.W.  exceeded the recommended dosage by using cortisone at least six times daily. Two to three times a day is recommended for using cortisone cream. When applied excessively, topical cortisone creams can lead to lipocortin production that blocks enzyme phospholipase A2, resulting in erythema and striae distensae (Niculet et al., 2020). Protein catabolism and increased mitotic activity caused the enzyme phospholipase to develop, which helps to reduce inflammation. As seen in striae distensae, the atrophy brought on by excessive topical steroid use can elevate the skin, create vasoconstriction, and cause itching.
  2. Week 4: Skin Comprehensive SOAP Note
  3. Cushing’s Syndrome: Cushing’s syndrome frequently presents as different skin disorders because of endogenous glucocorticoids and hypercortisolism. Although miscarriages are uncommon during pregnancy, they are highly likely when high blood pressure is present (Chaudhry & Singh, 2022). Striae distensae, a Cushing’s syndrome-related condition, results in dark, medium-sized to wide marks on the back, hips, thighs, and belly. Stretch marks are caused in patients with this illness by significant weight gain, high cortisol levels, and thin skin.

Week 4: Skin Comprehensive SOAP Note 

  1. Pruritic Urticarial and Plagues of Pregnancy (PUPPP): PUPPP can develop at the end of the second trimester and continue into the third trimester in places including the belly, legs, and forearms (Ishikawa-Nishimura et al., 2021). D.W.’s belly shows extensive striae, which she describes as itchy. Target lesions on the abdomen might appear in PUPPP patients as itchy, edematous eczema lesions resembling stretch marks or a combination of stretch marks and eczema. Owing to PUPPP’s pathophysiology, it frequently goes undetected and eludes treatment during pregnancy. In PUPPP, Th2 cytokines such as IL-9 and IL-33 are upregulated. These cytokines target body parts where there is an excess of cortisol and cause hyperpigmentation, skin eruptions, and patchy white lesions with stretch marks. (Week 4 – Skin Comprehensive SOAP Note)

Polymorphic Eruption of Pregnancy: Background, Epidemiology, Etiology

PLAN: This section is not required for the assignments in this course (NURS 6512), but will be required for future courses.

References

Barnawi, A. M., Barnawi, G. M., & Alamri, A. M. (2021). Women’s Health: Most Common Physiologic and Pathologic Cutaneous Manifestations During Pregnancy. Cureus, 13(7), e16539. https://doi.org/10.7759/cureus.16539

Chaudhry, H. S., & Singh, G. (2022). Cushing syndrome. In StatPearls [Internet]. StatPearls Publishing.

Dai, H., Liu, Y., Zhu, Y., Yu, Y., & Meng, L. (2021). Study on the methodology of striae gravidarum severity evaluation. Biomedical engineering online, 20(1), 109. https://doi.org/10.1186/s12938-021-00945-w

Florell, A. J., Wada, D. A., & Hawkes, J. E. (2017). Linear focal elastosis associated with exercise. JAAD case reports, 3(1), 39–41. https://doi.org/10.1016/j.jdcr.2016.10.012

Ishikawa-Nishimura, M., Kondo, M., Matsushima, Y., Habe, K., & Yamanaka, K. (2021). A Case of Pruritic Urticarial Papules and Plaques of Pregnancy: Pathophysiology and Serum Cytokine Profile. Case reports in dermatology, 13(1), 18-22. https://doi.org/10.1159/000511494

Niculet, E., Bobeica, C., & Tatu, A. L. (2020). Glucocorticoid-Induced Skin Atrophy: The Old and the New. Clinical, cosmetic and investigational dermatology, 13, 1041–1050. https://doi.org/10.2147/CCID.S224211

Oakley, A.M., & Patel, B.C. (2022). Stretch Marks. In: StatPearls [Internet]. StatPearls Publishing.

 
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Essay Help on Literature

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Essay Help on Literature

Literature in a broad context is any single meaning representation of written work. It was writing considered to have an artistic or intellectual benefit and deploys words in a way that is different from ordinary usage. Literature has life giving power that readers enjoy in the way of trying to gain a sense of them. It tries to bring peoples thoughts together since they read the same texts. Any form of literature work has the power to nourish any form of mediation anyone one has ever found and a mode of assimilation and tries to make us up. Different forms of literature try to bring and create the same environment using different words and styles. Same themes are explored in various writing materials using different representations of events. In appreciation for literature, a person can transcend what surrounds them through literacy, drawing personal strength and looking upon those who surround them. The power of words is used demonizing and criticizing the world and brings out the noblest and strong responses after role humanity never started on a brick age but with words, bitter and hateful words, words are the actual life and can separate the essence of life and death. In this paper, how different styles and wording have been used to bring out the same meaning and the representation of various themes will be depicted. (Essay Help on Literature)

Essay Help on Literature

Theme representation of different literature work

In a comparison of two essay works that draw their referencing from various novels, the use of the different representation of the same themes is portrayed. They all talk about humanity, injustices, death, religion, sacrifice and self-identity. Considering the book, thief in the essay about dreams, it talks about a young who goes to stay with the foster parents after her mother is reprimanded and her father drawn to the army during the world war in Nazi German rule. Liesel in her life fights with the inability to find herself but with the help of the wife of the town’s mayor, Ilsa, who realizes her power for books helps her towards self-identity. Leisel steals several books from Ilsa’s house that seems not to care and afterward presents an empty book to Liesel that he writes her story on.

The young girl is taught how to read and write by her foster father and in appreciation for literature to depict the injustice, brutality, and inhumanity. It reflects the realities of the Nazi German rule that lead to the death, quote, “six million Jews millions others in gas chambers showing the immense of inhumanity and brutality. It is her dream to be able to call out to the world and try to change the prevailing situation using her word and creativity. Everyone around her dies while sleep with the bombing in the Himmel Street and this makes her desperate enough to drop her book which is picked up by death but finds refuge in Ilsa’s house and later her father. In this book, discrimination over the Jews is clearly shown, and any attempt to help a Jew was the bravest thing to do as seen by her foster father, Han. Han’s life was saved by a Jewish soldier during World War 1 who sacrificed his life and in a way to pay back Han gives refuge to the Jewish son, Max and is later punished. Although Liesel steals book to read she can realize the value of life and show it to the world which was her long term dream

For a person to achieve their dreams, a lot of effort and sacrifice is essential, insisting on the vision, overcoming the temptations and following your instincts. The essay on dream also talks about a book The Ocean at the end of the lane of a man who is in search of self-identity caused by the disconnection between adulthood and childhood. He uses flashback to recall events that took place when he was a boy; he faced fights with the supernatural being that gained access into the world after an Opal Miner steals his father’s car and later committing suicide at the backseat for gambling away with friends’ money. A coin became lodged in the writer’s throat which from a neighbor it was a spirit and needed to be bounded but on the travel necessary to bind it he lets go of Lettie’s hand and a warm lodges in his foot and in an effort to pull it a piece remains which later he realizes it was the spiritual being. The spiritual being finds its way into the boy’s home as the maid where it gains control over her sister and father.

Ursula the spirit, after seducing his father, causes the boy to be alienated from his family and is nearly killed by his father in a bath tab. The narrator remains locked up in his bedroom and somehow manages to escape to the Hempstock farm. The Hempstock negotiates with the spirit that does not believe that any harm can come to her but later by “hunger birds.” Since the narrator has a piece of warm in him, the Hunger birds insist on eating the narrator’s heart, and he is kept in the safety of the property, Ocean. The inhumanity arises when the hunger birds begin to eat his world to force him to come out the property. The narrator tries to sacrifice himself for others, but Lettie intervenes by jumping in between him and the Hunger birds which injure her and transform her into a different world. She is placed in the ocean behind their house where she is to rest until she returns to this world. The narrator has a fading memory of the past and doesn’t recall his visits to the house. The memories are caused his heart slowly growing back which was indeed eaten by the hunger birds. The theme of inhumanity, death, and sacrifices towards the realization of the value of life are represented differently from the book Thief but are meant to achieve similar goals of exploring the value of life.

In a comparison with the essay about Small Gods, the same are also seen but in a different perspective. The book involves a great god Om and his prophet Brutha who together they work to fight zealotry where humans are attached to strong religious, cultural or political beliefs and cannot tolerate other conflicting ideas. The god Om wants to be restored to his former glory and power, and they have to discuss the nature of these beliefs. The narrator is a humanist and the themes of the relationship between man and God, fate, the universe and death. The discussion with the unbelievers is somehow difficult but how can you question God’s existence when every he keeps smiting you when you deny and I quote “Gods don’t like that sort of thing,’ said the barman.’ We get that in here some nights when someones has had a few. Cosmic speculations about whether gods exist. Next thing there is a bolt of lightning through the roof with a note wrapped on saying “yes, we do.”

In this text, death falls in love with humanity, and at some points, the god Om quits his job and becomes preoccupied with the fate of lack of power and believers; he seems to be in a fight for self-identity. However, the journey of the God proceeds with humanity becoming a great concern to him, and at some point, he asks questions of justice and fairness. In one scenario he begs the Sea Queen not to drown a ship full of people, and she tries to understand the concept and I quote,’ Sounds like a human idea to me, they are inventive, I will grant you. But what I meant is they have done nothing to deserve it. “Deserve? They are human, what does deserve got to do with it?’ Om has to concede that since he was not thinking like a god.

From a distant Om hears a whisper which is terrible and deity from the wind, a man slowly goes to his knees as death approaches in the desert of the afterlife. It is prophet Brutha who has seen the ugly side of humanity. He has gone through cruelty and brutality in the hands of humans he looked upon and the holy text he had dedicated his all life too. Besides all these, Brutha has the heart to forgive and still believe by letting the cycle of events breakdown violence and find his life instead of turning harsh and bitter. Actually, he realizes his strength in his weaknesses. Back in the desert of the afterlife, Brutha finds his enemies broken, defeated on the sand but instead Brutha takes the hand of his former torture and lifts him up and I quote,’ he was a terrible person. He died a hard death. So maybe. A queen can forgive her vanquished foe. It is not easy; it does not count if it is easy, it is the hardest thing. Forgiveness. Which is where love and justice finally meet? Peace, at last’.

All contexts in this paper also portray the religion or spirituality, Max the Jewish in the book Thief talks about the life of every creature. Max says that every living creature stays a life because it has a secret behind the life I quote,” in my religion we are taught that every living thing, every leaf, every bird is only alive because it contains the secret word for life. That is the only difference between and a lump of clay. A word, Words are life.” In the book Ocean at the End of the Lane, spiritually comes in a broader way, the people in supernatural beings that can find their way into the human world and gain control over them. The book on Small Gods also portrays religion in a different perspective; the narrator says that everything we encounter in life represents a small God. The Om God is reduced inside the body of a tortoise, and it is hard to convince people of his existence and power due to the belief that a God is mighty. Every book tries to bring out the same theme, but in a different perspective, this shows how words are used differently in literature from the standard meaning to achieve the same goal and create the same atmosphere and mediation in the minds of readers. You think the same with the same attitude and mood with the writer. (Essay Help on Literature)

Use of different situations and styles to achieve the same goal

Different circumstances and techniques have been used to achieve the same purpose every writer has his level of creativity and preference of the style to use. In the Book Thief, the narrator is the character in the story is told in a first person perspective to bring out her experience of inhumanity, Death, colonialism, self-identity. The book, The Ocean at the End of the Lane applies the use flashback to reconnect the narrator’s adulthood and childhood. The memories reflect life experience at childhood depicts the themes of brutality, sacrifice, self-identity and religion. The book Small Gods uses symbolism, where God Om is represented in the body of a tortoise to bring the authors message that everything we meet in life is a small god and there is need to practice humanity, justice, and fairness. (Essay Help on Literature)

Work Cited

Tuckman, Bruce W., and Brian E. Harper. Conducting educational research. Rowman & Littlefield Publishers, 2012.

https://rb.gy/7nvx36

 
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Applied Behavioral Analysis 2

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Applied Behavioral Analysis 2

Resource: How to Make a Graph Using Microsoft Excel

The Unit 6 Assignment requires you to apply the theories, concepts, and research that you have covered so far this term to a hypothetical case study. Your answers to the questions and completed graph should consist of information from the text and supplemental readings.You also may use sources from the Kaplan library or other credible Internet sources, but your primary sources should be the readings assigned for the course.

Read each Case Study and answer the questions below. You will need to write 2–3 typed pages for each case in order to address all required parts of the project.Answers to the questions should be typed in an APA formatted Word document, double-spaced in 12-point font and submitted to the Dropbox.

Your final paper must be your original work; plagiarism will not be tolerated. Be sure to review the Syllabus in terms of what constitutes plagiarism.Please make sure to provide proper credit for those sources used in your case study analysis in proper APA format. Please see the APA Quick Reference for any questions related to APA citations. You must credit authors when you:

Summarize a concept, theory or research
Use direct quotes from the text or articles
Read Case Study 1: Martin

Martin, a behavior analyst, is working with Sara, a 14-year-old girl with severe developmental delays who exhibits self-injurious behavior (SIB). Sara’s target behavior is defined as pulling her hair, biting her arm and banging her head against the wall. After conducting a functional analysis, Martin decided to employ an intervention program consisting of differential reinforcement of other (DRO) desired behavior. Martin collected data on Sara’s SIB before and during the intervention. Below is a depiction of the data that Martin collected:

Sara’s Frequency of SIB

BASELINE Occurrences DRO Occurrences
22 5
25 5
27 3
26 2

 

Address the following questions, and complete the following requirements:

Create a basic line graph using Microsoft Excel, to be included in your Word document. The graph should depict the data provided in this case study. You should only need to create one graph, with SIB depicted, both in baseline and in intervention.
What type of research design did Martin employ when working with Sara? What is an advantage and a disadvantage of using this research design?
According to the data in the graph, was the intervention that Martin selected effective in modifying Sara’s self-injurious behavior?
Martin had considered using an ABAB reversal design when working with Sara. What are some ethical implications of selecting a reversal design when working with the type of behavior problems that Sara was exhibiting?
Martin’s supervisor requested a graph of the data he collected when working with Sara. Why are graphs useful in evaluating behavior change?
Discuss how a graph demonstrates a functional relationship. Identify whether the graph that you created using the data provided in this section depicts a functional relationship.

 
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Visual Basic .Net 2012 Programming

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Card Shuffling and Dealing Simulation

Use Visual Basic .Net 2012 to program, debug, and test the following programming project.

 

Modify the Card Shuffling and Dealing Simulation  (reference chapter 9 – Case Study 9.5 Attached) to present the user with a video poker hand (5 card).

  • Change the main screen graphic to something of your own design.
  • For the cards, each card can be any available from a standard deck of cards.
  • Once a card is used, it cannot be used again in that hand (example: you draw the Jack of Hearts; you cannot draw that same card again).
  • When all 5 cards are shown on screen, allow the user to discard and draw new cards once (up to all 5 cards at a time, but only allow them to change the cards once).
  • Inform the user of their result in a dialog box (example: 3 of a kind or 2 pairs, etc.). After the user clears the result, allow the user to draw a hand again or exit the program.
  • All programs should have basic menu options that allow the user to exit the program and perform tasks you deem necessary for the program to function correctly. After creating the program, be sure to debug and test your code.
  • Submit a screenshot of the executed program and the code of the program.
 
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Artificial Intelligence 2

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1.Read chapter 5 from the PDF file and do Games Homework 1.

2. Read chapter 6 from the PDF file and do exercises 6-1 and 6-5.

For reference watch the 2 video’s at:
Video 1: http://csis.pace.edu/~benjamin/teaching/cs627online/webfiles/ConstraintSat isfaction1.mp4
Video 2: http://csis.pace.edu/~benjamin/teaching/cs627online/webfiles/ConstraintSat isfaction2.mp4

3. Read chapters 7 and 8 from the PDF file and do Logic Homework 1.

For reference watch only the first two videos at,

4. Read chapter 13 and sections 14.1 and 14.2 from the PDF file and do exercises 13-8 and 14-4.

For reference watch the 3 video’s at:
Video 1: http://csis.pace.edu/~benjamin/teaching/cs627online/webfiles/Probability1. mp4
Video 2: http://csis.pace.edu/~benjamin/teaching/cs627online/webfiles/Probability2. mp4

Video 3:

http://csis.pace.edu/~benjamin/teaching/cs627online/webfiles/Probability3. mp4

5. Read sections 18.1 through 18.3 from the PDF file and do Learning Homework 1.

For reference watch these videos:
I. http://videolectures.net/bootcamp07_guyon_itml/

II. https://www.youtube.com/watch?v=pLzE2Oh9QDI

 
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Use The Polarbear-GBI Answer Sheet To Submit Your Answers. The Two Excel File Provide Are Called For As You Go Through The Exercise.

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Exercises in Supply Chain Optimization and Simulation using anyLogistix

 

Prof. Dr. Dmitry Ivanov

Berlin School of Economics and Law

Professor of Supply Chain and Operations Management

Modified by Dr. Ed Lindoo, Campbellsville University, 2020.

 

To be cited as: Ivanov D. (2019). Exercises in Supply Chain Optimization and Simulation using anyLogistix, Berlin School of Economics and Law, 2nd, updated edition

© Prof. Dr. Dmitry Ivanov, 2019. All rights reserved.

1. Introduction

Supply chain network design and operational planning decisions can have a drastic impact on the profitability and success of a company. Whether to have one warehouse or two, close a factory or rent a new one, or to choose one network path over another are all consequential decisions a supply chain (SC) manager must make. However, these decisions must be the result of more than experience or intuition, and, as a result, research in SC management (SCM) is geared towards providing the data, tools, and models necessary for supporting SC managers’ analytical decisions. One of these decision-supporting tools is anyLogistix, a software which facilitates Greenfield Analysis, Network Optimization, and Simulation.

anyLogistix has become more and more popular with the provision of the free PLE version, and because it is an easy-to-use software, includes simulation and optimization, and covers all standard teaching topics (center-of-gravity, efficient vs responsive SC design, SC design through network optimization, inventory control simulation with safety stock computations, sourcing (single vs. multiple) and shipment (LTL vs FTL) policy simulation, and milk-run optimization).

The ALX exercise book addresses the application of quantitative analysis methods and software to decision-making in global supply chains and operations. Understanding of optimization and simulation methods in SCM is the core of the course. Technical skills for using simulation and optimization software in praxis can be acquired with the help of anyLogistix software. This case study is designed to stimulate and enhance conceptual and analytical decision-making skills in actual operating situations. The case method requires you to prepare a decision based on careful evaluation of case facts and numbers to the extent possible. As with all business situations, there may be insufficient facts, ambiguous goals, and dynamic environments.

This case seeks to convey the following skills:

Analytical Skills: Students will possess the analytical and critical thinking skills to evaluate issues faced in business and professional careers.

Technical Skills: Students will possess the necessary technological skills to analyze problems, develop solutions, and convey information using optimization and simulation software.

Along these lines, throughout the course we will examine two scenarios:

 Building a new SC from scratch -a case study of the Polarbear Bicycle company, which

must create and optimize its SC in order to maintain profitability and keep its competitive

edge in an increasingly global market where sales prices are driven down while costs re

main stable and seeks to analyze the performance of their existing SC and optimize its distribution network, while considering the risks and ripple effect.

Using the models available in anyLogistix, we will conduct analyses to (1) determine an optimal location using Greenfield Analysis (GFA) for a new warehouse, given the location of their current customers and those customers relative demands, (2) compare alternative network designs using Network Optimization (NO).

2. Case study

2.1 Description of Case Study

Customer Bicycle Type Demand per day
Cologne x-cross 2
Cologne urban 50
Cologne all terrain 15
Cologne tour 10
Bremen x-cross 7
Bremen urban 30
Bremen all terrain 20
Bremen tour 20
Frankfurt am Main x-cross 6
Frankfurt am Main urban 5
Frankfurt am Main all terrain 4
Frankfurt am Main tour 5
Stuttgart x-cross 15
Stuttgart urban 15
Stuttgart all terrain 1
Stuttgart tour 40
 

Costs

 Value in USD
Factory Nuremberg: fixed (other) costs, per day 15,000
Factory Poland: fixed (other) costs, per day 5,000
DC Germany: fixed (other) costs, per day 15,000
DC Germany: carrying costs (per bicycle) 3.00
DC Czech Republic: fixed (other) costs, per day 5,000
DC Czech Republic: carrying costs 2.00
DC Germany: processing costs (inbound and outbound shipping per pcs) 2.00
DC Czech Republic: processing costs (inbound and outbound shipping per pcs) 1.00
Factory Nuremberg: production costs (per bicycle) 250
Factory Poland: production (per bicycle) 150
All bicycles: product purchasing costs 30
Transportation costs; Paths: from factory -to DCs 0.01 * product(pcs) * distance
Transportation costs; Paths: from DCs -to customers 0.01 * product(pcs) * distance
Unit revenue 499
Table 1  

We consider a company called Polarbear Bicycle. Polarbear Bicycle was founded as an e-commerce start-up selling bicycles, however they were just purchased by the company you work for as an analyst……Global Bikes (GBI). With this new purchase, the board of directors of GBI is asking a number of questions that you as an analyst for GBI need to answer. Polarbear’s portfolio includes four different types of bicycles: x-cross, urban, all terrain, and tour bicycles. You have been assigned the task to find the best location for one or two new distribution centers (DC). First, you estimate customer demand based on Table 1 above. Polarbear distributes their bicycles to four locations throughout Germany: Cologne, Bremen, Frankfurt am Main, and Stuttgart. Table 1 shows customer demand, which is equal to 245 bicycles per day.

GBI now needs you to analyze supply and distribution network alternatives and to develop a best-case scenario for Polarbear-GBI Bicycle. You are charged with conducting a GFA to determine the possible location of a new DC or DC’s in Germany, as well as a network optimization to compare several options for network paths.

2.2 Greenfield Analysis (GFA) for Facility Location Planning: Selecting the Best

Warehouse Location for Polarbear-GBI Bicycle

Now we conduct a GFA for the outbound network of Polarbear-GBI Bicycle considering the four customers located in Cologne, Bremen, Frankfurt am Main, and Stuttgart. The aim of this GFA is to determine the optimal location of one (or two) new DC’s in Germany subject to total minimum transportation costs. Note: for the purposes of this analysis we are not considering current GBI customers or DC’s within Europe. Polarbear-GBI makes and sells very unique bicycles that currently are not a good fit within the GBI network, therefore we consider a completely separate distribution network.

Creating an ALX model.

Step 1. Open Anylogistix. Click on New Scenario, click OK. Next click on import scenario then select the file you downloaded, PB GFA Level 2 with Solutions.xlsx. Change the scenario name to your name

Note: You may receive a warning about old data file. You should be able to say OK and just ignore it.

Performing experiments. Data from Table 1 has already been entered for Customers, Demand, and Products.

 

Step 2. Go to GFA Experiment and run it for “Number of sites = 1” and the period of two months.

Select custom periods and make sure the default dates 11/1/17 – 12/31/17 are set.

Step 3. Analyze the results using statistics “Flows” and “New Sites”:

Note: Use the Polarbear-GBI case study answer sheet to submit ALL of your answers.

 

1. What are the optimal coordinates of the DC?

2. What is the maximum distance from the optimal DC location to a customer?

3. What is the minimum distance from the optimal DC location to a customer?

4. What are the total costs of the SC? (Note: to compute the sum of costs or flows in GFA Results, just slightly drag the heading of the column “Period” in table “Product flows” in the space over the table.

5. Compare the data in statistics “Flows”and Table“Demand”. Do we satisfy all customer demands from the optimal DC location? If Yes, why? If no, why?

Step 4. Go to GFA Experiment and run it for “Number of sites = 2”.

Step 5. Analyze the results using statistics “Flows” and “New Sites”:

6. What are the total costs of the SC?

7. Compare the results with one and two DCs in terms of costs and responsiveness.

8. What other costs were not considered in selecting the optimal facility location in the GFA?

2.3 Network Optimization (NO) for Facility Location Planning: Comparing Po

larbear’s Supply Chain Design Alternatives

After selling the bicycles from the newly established DC(s) according to the GFA results, Polarbear-GBI decided to produce their own bicycles. Their production facility has now been established in Nuremberg and 250 bikes are produced each day. Recently, they have received an offer from a Polish production factory to rent a DC in the Czech Republic at a reasonable price. The same company also wants to offer them rental of a factory in Warsaw, Poland, even though they already have one factory in Germany. Polarbear-GBI must now decide which SC design is more profitable:

 Option 1: DC in Germany and Factory in Germany

 Option 2: DC in Germany and Factory in Poland

 Option 3: DC in Czech Republic and Factory in Poland

 Option 4: DC in Czech Republic and Factory in Germany

In Fig. 1, the different possibilities for the path networks are shown. The dotted lines show possible alternatives and the solid lines the existing structure of Polarbear’s SC.

Figure 1. Network optimization alternatives

The aim of the NO is to determine which network design is optimal based on Polarbear’s selected KPIs, e.g., profit.

Therefore, the factory in Warsaw, Poland, the DC in the Czech Republic, and the DC in Steimelhagen were added as inputs to the model along with the Nuremburg factory. To enable the model’s calculation, the reality of the case must be simplified: all demand is assumed to be deterministic without any uncertain fluctuations. To define the two-stage NO problem (transport between factories and DCs and between DCs and customers) from a mathematical perspective, several parameters must be input as data. These are shown in Table 2.

 

The costs of the rent for the factory in Poland and the DC in Czech Republic are included in “othercosts”. For transport, it is always assumed that each truckload fits 80 bicycles, and trucks travel at a speed of 80 km/h.

Creating an ALX model

Step 0. Probably best to close and re-open ALX at this point. Now create an new scenario as you did in Step 1 above and import the file PB NO Level 2 Solution.xlsx. Rename it so that it has your name or initials as the scenario name: Note: Data from Table 2 has been entered for you.

Note: You may receive a warning about old data file. You should be able to say OK and just ignore it.

Performing experiments Step 1. Go to NO Experiment and run it with the Demand variation type “95-100%”.

NOTE! In order to run the NO experiment, make sure the units in experiment settings is set from m3 to pcs to align it with product data.

Step 2. Analyze the results using statistics “Optimization Results”, “Flow Details”, “Production Flows”, “Demand”, and “Overall Stats”:

 

b. place a screen shot here clearly showing your new NO results with your name or initials in the scenario name.

 

 

9. What is the most profitable SC design?

10. Is demand for all customers satisfied? Why or Why not?

11. What is the total revenue of the most profitable SC?

12. What is total profit of the most profitable SC?

13. Compare the data in statistics “Production Flows” and Table “Demand”. Does the production quantity correspond to the total demand? Explain.

14. Compare the optimal SC design as computed in the NO and the initial SC design (factory and DC in Germany) in terms of profit.

15. What other costs should be considered when redesigning the SC according to NO results?

16. What other factors, apart from costs, should be considered when re-designing the SC according to the results of the NO?

 
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Job Interview Presentation ( Fundamentals Of Networking)

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Job Interview Presentation

Your Name:

The interview will focus on networking fundamentals and consist of 10 questions.

Networking

Devices

Protocols

United States Cyber Command uses state-of-the art technology. However, the fundamentals are as important as any innovative technology. Given that, what are the three basic local area network (LAN) topologies called?

The national mission teams operate on all types of networks. To defend a network, you must first understand the network design on which you are operating. Provide a brief description of each of the following network topologies:

Topology​ Description​
bus​ ​
star​ ​
ring​ ​
mesh​ ​
hybrid​ ​
Our employees must have a theoretical and applicable understanding of how networking works. Name each layer of the OSI model. Provide the layer number and name from top to bottom.

Layer​ OSI Layer Name​
​ ​
​ ​
​ ​
​ ​
​ ​
​ ​
​ ​
Briefly describe each function of the OSI model layer. Provide the layer name and the function in your response.

Layer​ Function​
​ ​
​ ​
​ ​
​ ​
​ ​
​ ​
​ ​
United States Cyber Command requires an internet service provider (ISP) to connect to the internet. What is the point at which the operational control of ownership changes from the ISP to United States Cyber Command?

Our teams operate and encounter all types of devices. Provide a brief description of each of the following common network devices:

Networking Device​ Description​
hub​ ​
router​ ​
NIC​ ​
switch​ ​
The national mission teams require implementation of common protocols. Provide the port that each of the following protocols use:

Protocol​ Port​
HTTP​ ​
SMTP​ ​
SNMP​ ​
DNS​ ​
HTTPS​ ​
DHCP​ ​
TELNET​ ​
Provide the IP range for each network class:

Note: The question is asking for the class range, not the private IP range for each class.

Class A:

Class C:

Class B:

Provide the default subnet mask to the class of network:

Class​ Format​ Default Subnet Mask​
A​ network.host.host.host​ ​
B​ network.network.host.host​ ​
C​ network.network.network.host​ ​
Describe the purpose of an autonomous system.

Thank You!

Upload your PowerPoint and video to the Assignments folder to receive a grade and feedback.

 
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