NRNP 6540 Week 9 RaymondYoung Assignment
To prepare:
- Review the case study provided below
- Reflect on the patient’s symptoms and aspects of disorders that may be present.
- Consider how you might assess, perform diagnostic tests, and recommend medications to treat patients presenting with the symptoms in the case.
- Access the Focused SOAP Note Template in this week’s Resources.
The Assignment:
Complete the Focused SOAP Note Template provided for the patient in the case study. Be sure to address the following:
- Subjective: What was the patient’s subjective complaint? What details did the patient provide regarding their history of present illness and personal and medical history? Include a list of prescription and over-the-counter drugs the patient is currently taking. Compare this list to the American Geriatrics Society Beers Criteria®, and consider alternative drugs if appropriate. Provide a review of systems.
- Objective: What observations did you note from the physical assessment? What were the lab, imaging, or functional assessment results?
- Assessment: Provide a minimum of three differential diagnoses. List them from top priority to least priority. Compare the diagnostic criteria for each, and explain what rules each differential is in or out. Explain the critical thinking process that led you to your primary diagnosis. Include pertinent positives and pertinent negatives for the specific patient case.
- Plan: Provide a detailed treatment plan for the patient that addresses each diagnosis, as applicable. Include documentation of diagnostic studies that will be obtained, referrals to other health-care providers, therapeutic interventions, education, disposition of the patient, caregiver support, and any planned follow-up visits. Provide a discussion of health promotion and disease prevention for the patient, taking into consideration patient factors, past medical history (PMH), and other risk factors. Finally, include a reflection statement on the case that describes insights or lessons learned.
- Provide at least three evidence-based peer-reviewed journal articles or evidenced-based guidelines, which relate to this case to support your diagnostics and differential diagnoses. Be sure they are current (no more than five years old) and support the treatment plan in following current standards of care. Follow APA 7th edition formatting.
HPI: Ms. Juggenmeir is a 71-year-old Female who comes into your office with concerns about fatigue and dry skin. She is a retired Banker. She is AAOx4, ambulatory, and lives by herself. She does report increased fatigue no matter how much sleep she gets. She is also concerned that she may need to come off one of her meds because her hair is thinning. She had labs done and was informed they would review the results at this visit. Other pertinent diagnoses include Hypertension, Hyperlipidemia, and Vitamin D deficiency. She admits to not taking her vitamin D daily as prescribed.
RESOURCE FOR THIS WEEK: Review Endocrine-related Evidence-Based Practice Guidelines.
Ms. Juggenmeir is a 71 y/o female who is AAOX4. She makes no unusual motor movements and demonstrates no tics. She denies any visual or auditory hallucinations. She denies any suicidal thoughts or ideations. She denies any falls or pain.
(All other Review of System and Physical Exam findings are negative other than stated.)
Vital Signs: BP 137/82, HR 89, RR 20, Temp 98.1
PMH: Hypertension, Hyperlipidemia, Vitamin D deficiency
Allergies: I.V. Contrast, ACE Inhibitors
Medications:
Women’s One A Day-Multivitamin daily
Chlorthalidone 25mg daily
Fish Oil 1 tablet daily
Amlodipine 5mg p.o. daily
Losartan 100mg p.o. daily
Atorvastatin 40mg p.o. at bedtime daily
Aspirin 81mg p.o. daily
Ergocalciferol 50,000 units PO once a month
Social History: as stated in the Case Study
ROS: as stated in the Case study
Diagnostics/Assessments done:
- CXR – The last CXR showed no cardiopulmonary findings. WNL
- TSH/Free T4, T3 – as noted below in lab results
- Basic Metabolic Panel and CBC as shown below
- Vitamin D Level – as noted below in lab results
| TEST | RESULT | REFERENCE RANGE |
| GLUCOSE | 85 | 65-99 |
| SODIUM | 134 | 135-146 |
| POTASSIUM | 4.2 | 3.5-5.3 |
| CHLORIDE | 104 | 98-110 |
| CARBON DIOXIDE | 29 | 19-30 |
| CALCIUM | 9.0 | 8.6- 10.3 |
| BUN | 20 | 7-25 |
| CREATININE | 1.01 | 0.70-1.25 |
| GLOMERULAR FILTRATION RATE (eGFR) | 76 | >or=60 mL/min/1.73m2 |
| TEST | RESULT | REFERENCE RANGE |
| TSH | 23 | 0.4-4.0 |
| FREE T4 | 0.05 | 0.9-2.4 mcg/dl |
| T3 | 3.0 | 2.0-4.4 ng/dl |
| Vitamin D 1,25 OH | 14 | 36-144 |
| TEST | RESULT | REFERENCE RANGE |
| WBC | 7.3 | 3.4- 10.8 |
| RBC | 4.31 | 135-146 |
| HEMOGLOBIN | 14 | 13-17.2 |
| HEMATOCRIT | 42% | 36-50 |
| MCV | 90 | 80-100 |
| MCHC | 34 | 32-36 |
| PLATELET | 272 | 150-400 |
NRNP_6540_Week9_Assignment_Rubric
NRNP_6540_Week9_Assignment_Rubric
Criteria Ratings Pts
This criterion is linked to a Learning OutcomeCreate documentation in the Focused SOAP Note Template about the patient in the case study to which you were assigned. In the Subjective section, provide: • Chief complaint• History of present illness (HPI) • Current medications, checked against Beers Criteria• Allergies• Patient medical history (PMHx) • Review of systems
10 to >9.0 ptsExcellent
The response throughly and accurately describes the patient’s subjective complaint, history of present illness, current medications, allergies, medical history, and review of all systems that would inform a differential diagnosis. A thorough cross-check of medications against the Beers Criteria has been completed and appropriate alternative drugs recommended if applicable.
9 to >8.0 ptsGood
The response accurately describes the patient’s subjective complaint, history of present illness, current medications, allergies, medical history, and review of all systems that would inform a differential diagnosis. A cross-check of medications against the Beers Criteria has been completed and appropriate alternative drugs recommended if applicable.
8 to >7.0 ptsFair
The response describes the patient’s subjective complaint, history of present illness, current medications, allergies, medical history, and review of all systems that would inform a differential diagnosis, but is somewhat vague or contains minor innacuracies. A cross-check of medications against the Beers Criteria has been completed but alternatives may be missing.
7 to >0 ptsPoor
The response provides an incomplete or inaccurate description of the patient’s subjective complaint, history of present illness, current medications, allergies, medical history, and review of all systems that would inform a differential diagnosis. A cross-check of medications against the Beers Criteria has not been completed. Or, subjective documentation is missing.
10 pts
This criterion is linked to a Learning OutcomeIn the Objective section, provide: • Physical exam documentation of systems pertinent to the chief complaint, HPI, and history• Diagnostic results, including any labs, imaging, or other assessments needed to develop the differential diagnoses
10 to >9.0 ptsExcellent
The response thoroughly and accurately documents the patient’s physical exam for pertinent systems. Diagnostic tests and their results are thoroughly and accurately documented.
9 to >8.0 ptsGood
The response accurately documents the patient’s physical exam for pertinent systems. Diagnostic tests and their results are accurately documented.
8 to >7.0 ptsFair
Documentation of the patient’s physical exam is somewhat vague or contains minor innacuracies. Diagnostic tests and their results are documented but contain minor innacuracies.
7 to >0 ptsPoor
The response provides incomplete or inaccurate documentation of the patient’s physical exam. Systems may have been unnecessarily reviewed, or, objective documentation is missing.
10 pts
This criterion is linked to a Learning OutcomeIn the Assessment section, provide: • At least three (3) differentials with supporting evidence. Explain what rules each differential in or out, and justify your primary diagnosis selection. Include pertinent positives and pertinent negatives for the specific patient case.
25 to >23.0 ptsExcellent
The response lists in order of priority at least three distinctly different and detailed possible conditions for a differential diagnosis of the patient in the assigned case study, and provides a thorough, accurate, and detailed justification for each of the conditions selected.
23 to >20.0 ptsGood
The response lists in order of priority at least three different possible conditions for a differential diagnosis of the patient in the assigned case study and provides an accurate justification for each of the conditions selected.
20 to >18.0 ptsFair
The response lists three possible conditions for a differential diagnosis of the patient in the assigned case study, with some vagueness and/or inaccuracy in the conditions and/or justification for each.
18 to >0 ptsPoor
The response lists two or fewer, or is missing, possible conditions for a differential diagnosis of the patient in the assigned case study, with inaccurate or missing justification for each condition selected.
25 pts
This criterion is linked to a Learning OutcomeIn the Plan section, provide: • A detailed treatment plan for the patient that addresses each diagnosis, as applicable. Includes documentation of diagnostic studies that will be obtained, referrals to other health-care providers, therapeutic interventions, education, disposition of the patient, and any planned follow up visits. • A discussion related to health promotion and disease prevention taking into consideration patient factors, PMH, and other risk factors. • Reflections on the case describing insights or lessons learned.
30 to >27.0 ptsExcellent
The response thoroughly and accurately outlines a treatment plan for the patient that addresses each diagnosis and includes diagnostic studies neeed, referrals, therapeutic interventions, patient education and disposition, and planned follow-up visits. A thorough and accurate discussion of health promotion and disease prevention related to the case is provided. Reflections on the case demonstrate strong critical thinking and synthesis of ideas.
27 to >24.0 ptsGood
The response accurately outlines a treatment plan for the patient that addresses each diagnosis and includes diagnostic studies neeed, referrals, therapeutic interventions, patient education and disposition, and planned follow-up visits. An accurate discussion of health promotion and disease prevention related to the case is provided. Reflections on the case demonstrate critical thinking.
24 to >21.0 ptsFair
The response somewhat vaguely or inaccurately outlines a treatment plan for the patient. The discussion on health promotion and disease prevention related to the case is somewhat vague or contains inaccuracies. Reflections on the case demonstrate adequate understanding of course topics.
21 to >0 ptsPoor
The response does not address all diagnoses or is missing elements of the treatment plan. The discussion on health promotion and disease prevention related to the case is vague, innaccurate, or missing. Reflections on the case are vague or missing.
30 pts
This criterion is linked to a Learning outcome of at least three evidence-based peer-reviewed journal articles or evidenced-based guidelines that relate to this case to support your diagnostics and differential diagnoses. Be sure they are current (no more than five years old) and support the treatment plan in following current standards of care.
10 to >9.0 ptsExcellent
The response provides at least three current, evidence-based resources from the literature to support the treatment plan for the patient in the assigned case study. Each resource represents the latest in standards of care and provides strong justification for treatment decisions.
9 to >8.0 ptsGood
The response provides at least three current, evidence-based resources from the literature to support the treatment plan for the patient in the assigned case study. Each resource represents current standards of care and supports treatment decisions.
8 to >7.0 ptsFair
Three evidence-based resources are provided to support treatment decisions, but may not represent the latest in standards of care or may only provide vague or weak justification for the treatment plan.
7 to >0 ptsPoor
Two or fewer resources are provided to support treatment decisions. The resources may not be current or evidence-based or do not support the treatment plan.
10 pts
This criterion is linked to a Learning outcome Expression and Formatting—Paragraph Development and Organization: Paragraphs make clear points that support well-developed ideas, flow logically, and demonstrate continuity of ideas. Sentences are carefully focused–neither long, rambling, short, and lacking substance. A clear and comprehensive purpose statement and introduction are provided that delineate all required criteria.
5 to >4.0 ptsExcellent
Paragraphs and sentences follow writing standards for flow, continuity, and clarity. A clear and comprehensive purpose statement, introduction, and conclusion are provided that delineate all required criteria.
4 to >3.0 ptsGood
Paragraphs and sentences follow writing standards for flow, continuity, and clarity 80% of the time. The assignment’s purpose, introduction, and conclusion are stated, yet are brief and not descriptive.
3 to >2.0 ptsFair
Paragraphs and sentences follow writing standards for flow, continuity, and clarity 60%–79% of the time. The assignment’s purpose, introduction, and conclusion are vague or off-topic.
2 to >0 ptsPoor
Paragraphs and sentences follow writing standards for flow, continuity, and clarity < 60% of the time. No purpose statement, introduction, or conclusion were provided.
5 pts
This criterion is linked to a Learning outcome Expression and Formatting—English writing standards: Correct grammar, mechanics, and proper punctuation
5 to >4.0 ptsExcellent
Uses correct grammar, spelling, and punctuation with no errors.
4 to >3.0 ptsGood
Contains a few (one or two) grammar, spelling, and punctuation errors.
3 to >2.0 ptsFair
Contains several (three or four) grammar, spelling, and punctuation errors.
2 to >0 ptsPoor
Contains many (≥ five) grammar, spelling, and punctuation errors that interfere with the reader’s understanding.
5 pts
This criterion is linked to a Learning outcome. Expression and Formatting – The paper follows the correct APA format for the title page, headings, font, spacing, margins, indentations, page numbers, running heads, parenthetical/in-text citations, and reference list.
5 to >4.0 ptsExcellent
Uses the correct APA format with no errors.
4 to >3.0 ptsGood
Contains a few (one or two) APA format errors.
3 to >2.0 ptsFair
Contains several (three or four) APA format errors.
2 to >0 ptsPoor
Contains many (≥ five) APA format errors.
5 pts
Total Points: 100