WEEK 6 CASE STUDY ASSIGNMENT: ASSESSING, DIAGNOSING, AND TREATING PATIENTS WITH COMPLEX CONDITIONS.
WEEK 6 CASE STUDY ASSIGNMENT: ASSESSING, DIAGNOSING, AND TREATING PATIENTS WITH COMPLEX CONDITIONS.
Focused SOAP Note Template
Patient Information:
ED, 69 years, male
S.
CC (chief complaint): “Fever, chills, cough, and fatigue”
HPI: Edwin is a 69-year-old male who presented to the facility with complaints of a fever chills, cough, and feeling fatigued for the past few days. Edwin reports that he did not take his temperature because he did not have a thermometer but noted that he felt hot. According to him, he coughs up a little phlegm and experiences pain when he takes a deep breath. He also reports that his appetite has been poor. He has been taking Tylenol with minimal relief and drinking teas to try to break up the phlegm.
Current Medications: Edwin reports that he has been taking Tylenol with minimum relief
Allergies: none
PMHx: Edwin has a history of Crohn’s disease and a recent evaluation for CP and leg cramps. He has no history of surgeries.
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Soc & Substance Hx: Edwin is a non-smoker and non-drinker.
Fam Hx: No significant family history has been provided
Surgical Hx: Edwin has no history of surgery
Mental Hx: Edwin has no history of psychiatric diagnosis or treatment
Violence Hx: Edwin has no concerns about violence
Reproductive Hx: Edwin has no history of sexually transmitted infections, urgency, dysuria, or frequency
ROS:
GENERAL: Edwin reports fever, chills, and fatigue
HEENT: Eyes: Edwin denies the use of corrective lenses, vision loss, blurred vision, or tearfulness. Ears, Nose, Throat: Edwin has no hearing loss, ear pain nasal drainage, or a sore throat.
SKIN: Edwin denies skin rashes
CARDIOVASCULAR: Edwin reports chest pain with breathing in. He denies chest discomfort or palpitations.
RESPIRATORY: Edwin reports a productive cough with no shortness of breath.
GASTROINTESTINAL: Edwin does not have nausea, vomiting, or diarrhea.
GENITOURINARY: Edwin denies burning on urination, urgency, or frequency.
NEUROLOGICAL: Edwin does not have a headache, syncope, dizziness, or paralysis.
MUSCULOSKELETAL: Edwin has a full range of motion without muscle or joint pain.
HEMATOLOGIC: Edwin is not anemic. He has no history of blood transfusion.
LYMPHATICS: Edwin’s lymph nodes are not enlarged.
PSYCHIATRIC: There is no history of psychiatric conditions
ENDOCRINOLOGIC: Edwin denies heat or cold intolerance or weight changes
REPRODUCTIVE: Edwin denies purulent penile discharge
ALLERGIES: No history of allergies.
O.
Physical exam:
Vitals: BP 130/80, P 84, RR 14, T 103.2, SPO2 94%
Respiratory: There are decreased rales and rhonchi, which are more pronounced in the left lower lung fields. There is increased fremitus and dullness to percussion. Chest x-ray reveals a consolidation in the left lower lobe.
Cardiovascular: Presence of S1 and S2 heart sounds. S3 and S4 heart sounds are absent.
Diagnostic results: A chest x-ray was ordered. The results revealed a consolidation in the left lower lobe.
A.
Differential Diagnoses:
Pneumonia (J 18.9): Pneumonia is Edwin’s primary diagnosis. Pneumonia is an infection of the lung parenchyma. The affected patients present to the hospital with complaints such as fever with chills, loss of appetite, myalgias, and malaise. They also experience pulmonary complaints such as cough with or without sputum production and blood-tinge sputum in some cases (Olson & Davis, 2020). Other symptoms include tachypnea and tachycardia. Physical examination findings reveal decreased breath sounds, bronchial sounds, egophony, tactile fremitus, crackles on the affected lung regions, and dullness on percussion. Chest X-rays would reveal consolidation, lobar, and interstitial infiltrate (Jain et al., 2024). Edwin’s subjective and objective findings confirm pneumonia as his primary diagnosis. For example, he has a fever with chills, decreased appetite, productive cough, and consolidation on chest x-ray, hence, the diagnosis.
Tuberculosis (TB) (A 15.0): TB is one of the differential diagnoses that should be considered for Edwin. TB is a multi-organ infection caused by Mycobacterium tuberculosis. The affected patients usually present to the hospital with complaints of a chronic cough, blood-stained sputum, fever, night sweats, and unintentional weight loss (Gill et al., 2022). Edwin is least likely to be suffering from TB because of the absence of symptoms such as night sweats, bloodstained sputum, and lack of patches in the chest x-ray findings.
Asthma (J 45.909): Asthma is the other differential diagnosis that should be considered for Edwin. Asthma is a chronic disease of the airways that causes airway inflammation and narrowing. Patients often experience symptoms such as cough, wheezing, shortness of breath, chest pain, and tachypnea (Trzil, 2020). The presence of fever with chills rule out asthma in Edwin’s case. The presence of a fever shows that he has an infection.
Bronchitis (J 20.9): Bronchitis is the other differential that should be considered for Edwin. Bronchitis is a respiratory condition characterized by bronchial lining inflammation. It typically affects individuals with chronic obstructive pulmonary disease. Patients usually experience symptoms such as having a productive cough, malaise, wheezing, breathing difficulties, and body aches. Chest x-ray findings usually appear normal or can reveal bronchial wall thickening (Singh et al., 2024). Despite Edwin having symptoms such as a productive cough, chest x-ray findings suggestive of pneumonia rule out bronchitis.
P.
A chest x-ray was obtained to develop an accurate diagnosis of Edwin’s problem. Additional laboratory investigations such as sputum tests and a complete blood count should be ordered to determine the actual cause of his respiratory problem and rule out other problems. Antibiotics are the primary drugs of choice for pneumonia. Empiric therapy should be initiated until the cause of pneumonia is identified. Edwin’s condition requires outpatient management with fluoroquinolones or beta-lactams plus macrolides. An example of his prescription is oral ciprofloxacin 500 mg once daily for ten days (Jain et al., 2024). Edwin should be educated on the importance of treatment adherence, effective cough practices, waste disposal, hand hygiene, and signs and symptoms of worsening health status. A follow-up visit should be scheduled after a week to assess his treatment response. A referral to specialized care is not appropriate at this time because of his symptoms.
I learned from Edwin’s case the importance of considering different respiratory conditions when assessing, diagnosing, and treating respiratory problems. Healthcare providers should order additional laboratory and diagnostic investigations to help them develop accurate diagnoses. Health promotion interventions such as health education should also be incorporated into the treatment to enhance outcomes. I connected findings such as fremitus and dullness on assessment to the affected lung fields. The presence of consolidation in the left lower lobe confirmed my suspicion of lobar pneumonia.
References
Gill, C. M., Dolan, L., Piggott, L. M., & McLaughlin, A. M. (2022). New developments in tuberculosis diagnosis and treatment. Breathe, 18(1). https://doi.org/10.1183/20734735.0149-2021
Jain, V., Vashisht, R., Yilmaz, G., & Bhardwaj, A. (2024). Pneumonia Pathology. In StatPearls. StatPearls Publishing. http://www.ncbi.nlm.nih.gov/books/NBK526116/
Olson, G., & Davis, A. M. (2020). Diagnosis and Treatment of Adults With Community-Acquired Pneumonia. JAMA, 323(9), 885–886. https://doi.org/10.1001/jama.2019.21118
Singh, A., Avula, A., Sankari, A., & Zahn, E. (2024). Acute Bronchitis. In StatPearls. StatPearls Publishing. http://www.ncbi.nlm.nih.gov/books/NBK448067/
Trzil, J. E. (2020). Feline Asthma: Diagnostic and Treatment Update. Veterinary Clinics: Small Animal Practice, 50(2), 375–391. https://doi.org/10.1016/j.cvsm.2019.10.002
ASSESSING, DIAGNOSING, AND TREATING PATIENTS WITH COMPLEX CONDITIONS
For this Assignment, you will be assigned a complex patient case study with conditions related to any of the topics covered in Weeks 4–6. This includes cardiovascular, pulmonary, gastrointestinal, renal, musculoskeletal, and neurological conditions.
RESOURCES
Be sure to review the Learning Resources before completing this activity.
Click the weekly resources link to access the resources.
WEEKLY RESOURCES
To Prepare:
Review this and previous weeks’ Learning Resources as needed.
Review the case study provided by your Instructor. Based on the provided patient information, think about the health history you would need to collect from the patient.
Consider what physical exams and diagnostic tests would be appropriate in order to gather more information about the patient’s condition. Reflect on how the results would be used to make a diagnosis.
Identify three to five possible conditions that may be considered in a differential diagnosis for the patient.
Consider each patient’s diagnosis. Think about clinical guidelines that might support this diagnosis.
Develop a treatment plan for the patient that includes health promotion and patient education strategies for patients with their condition(s).
The Assignment:
Use the Focused SOAP Note Template to address the following:
Subjective: What details are provided regarding the patient’s personal and medical history?
Objective: What observations did you make during the physical assessment? Include pertinent positive and negative physical exam findings. Describe whether the patient presented with any morbidities or psychosocial issues.
Assessment: Explain your differential diagnoses, providing a minimum of three. List them from highest priority to lowest priority and include their CPT and ICD-10 codes for the diagnosis. What would your primary diagnosis be and why?
Plan: Explain your plan for diagnostics and primary diagnosis. What would your plan be for treatment and management? Include pharmacologic and non-pharmacologic treatments, alternative therapies, and follow-up parameters as well as a rationale for this treatment and management plan.
Reflection notes: Describe your “aha!” moments from analyzing this case.
BY DAY 7
Submit your focused SOAP note.
SUBMISSION INFORMATION
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To submit your completed assignment, save your Assignment as WK6Assgn_LastName_Firstinitial
Then, click on Start Assignment near the top of the page.
Next, click on Upload File and select Submit Assignment for review.
Rubric
NRNP_6568_Week6_Assignment_Rubric
NRNP_6568_Week6_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• Allergies• Patient medical history (PMHx) • Review of systems |
| 10 to >8.0 ptsExcellent 90%–100%
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. |
8 to >7.0 ptsGood 80%–89%
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. |
7 to >6.0 ptsFair 70%–79%
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 it is somewhat vague or contains minor innacuracies. |
6 to >0 ptsPoor 0%–69%
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. 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 >8.0 ptsExcellent 90%–100%
The response thoroughly and accurately documents the patient’s physical exam for pertinent systems. Diagnostic tests and their results are thoroughly and accurately documented. |
8 to >7.0 ptsGood 80%–89%
The response accurately documents the patient’s physical exam for pertinent systems. Diagnostic tests and their results are accurately documented. |
7 to >6.0 ptsFair 70%–79%
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. |
6 to >0 ptsPoor 0%–69%
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 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 >22.0 ptsExcellent 90%–100%
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 it provides a thorough, accurate, and detailed justification for each of the conditions selected. |
22 to >19.0 ptsGood 80%–89%
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 it provides an accurate justification for each of the conditions selected. |
19 to >17.0 ptsFair 70%–79%
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. |
17 to >0 ptsPoor 0%–69%
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 healthcare 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 >26.0 ptsExcellent 90%–100%
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. |
26 to >23.0 ptsGood 80%–89%
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. |
23 to >20.0 ptsFair 70%–79%
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 innaccuracies. Reflections on the case demonstrate adequate understanding of course topics. |
20 to >0 ptsPoor 0%–69%
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 OutcomeProvide at least three evidence-based, peer-reviewed journal articles or evidenced-based guidelines that relate to this case to support your diagnostics and differentials diagnoses. Be sure they are current (no more than 5 years old) and support the treatment plan in following current standards of care. |
| 10 to >8.0 ptsExcellent 90%–100%
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. |
8 to >7.0 ptsGood 80%–89%
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. |
7 to >6.0 ptsFair 70%–79%
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. |
6 to >0 ptsPoor 0%–69%
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 OutcomeWritten 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 and rambling nor short and lacking substance. A clear and comprehensive purpose statement and introduction are provided that delineate all required criteria. |
| 5 to >4.0 ptsExcellent 90%–100%
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 80%–89%
Paragraphs and sentences follow writing standards for flow, continuity, and clarity 80% of the time. Purpose, introduction, and conclusion of the assignment are stated, yet are brief and not descriptive. |
3 to >2.0 ptsFair 70%–79%
Paragraphs and sentences follow writing standards for flow, continuity, and clarity 60%–79% of the time. Purpose, introduction, and conclusion of the assignment are vague or off topic. |
2 to >0 ptsPoor 0%–69%
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 OutcomeWritten Expression and Formatting – English Writing Standards: Correct grammar, mechanics, and proper punctuation |
| 5 to >4.0 ptsExcellent 90%–100%
Uses correct grammar, spelling, and punctuation with no errors. |
4 to >3.0 ptsGood 80%–89%
Contains 1 or 2 grammar, spelling, and punctuation errors. |
3 to >2.0 ptsFair 70%–79%
Contains several (3 or 4) grammar, spelling, and punctuation errors. |
2 to >0 ptsPoor 0%–69%
Contains many (≥ 5) grammar, spelling, and punctuation errors that interfere with the reader’s understanding. |
|
5 pts |
| This criterion is linked to a Learning OutcomeWritten Expression and Formatting – The paper follows correct APA format for title page, headings, font, spacing, margins, indentations, page numbers, running heads, parenthetical/narrative in-text citations, and reference list. |
| 5 to >4.0 ptsExcellent 90%–100%
Uses correct APA format with no errors. |
4 to >3.0 ptsGood 80%–89%
Contains 1 or 2 APA format errors. |
3 to >2.0 ptsFair 70%–79%
Contains several (3 or 4) APA format errors. |
2 to >0 ptsPoor 0%–69%
Contains many (≥ 5) APA format errors. |
|
5 pts |
| Total Points: 100 |
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