NRNP 6540 Week 2 Assignment: Focused SOAP Note Essay

NRNP 6540 Week 2 Assignment: Focused SOAP Note Essay

NRNP 6540 Week 2 Assignment: Focused SOAP Note Essay

Patient Information:

C.W. 67-year-old, African American female

S: (subjective)

CC: client is brought to the clinic with concerns of “forgetfulness” of more recent things but easily recalls historical moments and events.

HPI: 67-year-old African American female, has been demonstrating forgetfulness for the last four years. She forgets more recent events but easily recalls historical events. She also has a challenge finding the right words in a conversation and shifts entirely to a different conversation. The Patient also laughs off important things she has forgotten and is upset when someone points them out.     

Current Medications: Amlodipine 10mg daily- for hypertension

HCTZ 12.5mg daily- For hypertension

Multivitamin daily- used to boost immunity and promote bone health

Atorvastatin 40mg daily- prescribed for hyperlipidemia

Alendronate 70mg once per week- prescribed for osteoporosis

The American Geriatrics Society Beers Criteria lists the medication that should not be used in older adults or Potentially Inappropriate Medication (PIM) use, due to increased risk factors and other drug-drug reactions (2019 American Geriatrics Society Beers Criteria, 2019). None of the medications listed above is in the American Geriatrics Society Beers Criteria list of PIM, thus safe for this client. Therefore, there is no need to recommend alternative drugs.

Allergies: Allergic to penicillin and Lisinopril. Both medications cause anaphylaxis allergic reactions, presenting symptoms such as hives, difficulty breathing, swelling, and severe skin reactions.

PMHx: All immunizations are up to date. Major illnesses are hypertension, hyperlipidemia, and osteoporosis. No history of past major surgeries.

Soc and Substance Hx: The client is a retired teacher. She has been living with her daughter for the last four years. Her husband passed on four years ago. She does not use tobacco, alcohol, or other drugs/substances. She enjoys meeting her friends at the local community center. She also has strong friendship ties. The client’s house has working smoke detectors to enhance safety.

Fam Hx: Both parents are deceased; father had dementia. Her sister, 71, is hypertensive. Has two children: the son is diabetic, the daughter is healthy. No family history of other major illnesses. with possible genetic predisposition, contagious, or chronic illnesses.

Surgical Hx: No history of major surgical procedures.

Mental Hx: Has not been diagnosed or treated of any mental illness. No concerns of anxiety or depression. No history of self-harm practices or suicidal or homicidal ideations.

Violence Hx: No history of personal, home, or community violence cases compromising safety.

Reproductive Hx: LMP at 44 years. Used oral contraceptives. Heterosexual. No sexual concerns.

ROS

GENERAL: denies weight loss, fever, chills, general weakness, or fatigue.

HEENT:

• Eyes: denies visual loss, blurred vision, double vision, or yellow sclerae.
• Ears, Nose, Throat: denies hearing loss. Denies sneezing, congestion, runny nose, or sore throat.

SKIN: denies rash or itching.

CARDIOVASCULAR: denies chest pain, chest pressure, or chest discomfort. No palpitations or edema.

RESPIRATORY: Denies shortness of breath, cough, or sputum.

GASTROINTESTINAL: denies nausea, anorexia, vomiting, or diarrhea. Reports no abdominal pain or blood.

GENITOURINARY: Reports no burning sensation on urination.

NEUROLOGICAL: denies headache, dizziness, syncope, paralysis, ataxia, numbness, or tingling in the extremities. Reports no change in bowel or bladder control.

MUSCULOSKELETAL: reports no muscle pain, back pain, joint pain, or stiffness. Denies muscle swelling

HEMATOLOGIC: reports no anemia, bleeding, or bruising.

LYMPHATICS: No enlarged nodes. Denies history of splenectomy.

PSYCHIATRIC: No history of depression. Reports feeling anxious occasionally

ENDOCRINOLOGIC: Reports no excessive sweating. Denies cold or heat intolerance. Denies polyuria or polydipsia.

REPRODUCTIVE: Not pregnant and no recent pregnancy. No reports of vaginal discharge. Not sexually active.

ALLERGIES: No history of asthma, hives, eczema, or rhinitis.

O (objective)

Physical exam:

Vital signs: BP 186/84 HR 74 RR 16. Weight 79kg Height 5’ 6” BMI 28.1

General: Client is A&O, appears relaxed with no apparent distress

HEENT: Head normocephalic, no masses, normal scalp hair distribution. PERRLA bilaterally, EOMI. Eyelids conjunctiva pink, no lesions, white sclera. TM intact and pearly gray. Oral mucosa moist, no lesions. No sinus tenderness. Full ROM without clicks. No lymphadenopathy. Thyroid smooth.

Musculoskeletal: No swelling, masses, or deformities on the neck and upper extremities. Fingernails have no ridges or abnormalities. Pink nailbeds. No lesions or deformities in the lower extremities. Full ROM on the neck and extremities. Neck and extremities strength 5/5.

Neurological: steady gait. Movement and coordination smooth and accurate, poor concentration. Deep tendon reflexes 2+. Disorientation and confusion present. Primitive reflexes present.

Based on the mini-mental status exam, the client is cooperative, alert and maintains fair eye contact. She has a clear speech, but occasionally tangential. No unusual movements demonstrated. She denies hallucinations, suicidal thoughts and ideations, and she is disoriented to time and place. The overall mental status exam score is 18/30, with deficits in attention, recall, orientation, and registration, suggesting moderate dementia.       

Diagnostic results:

The diagnostic assessments done include CXR, head CT scan, and a mini-mental status exam. Hemmy et al. (2020) note that other diagnostic assessments required to develop differential diagnoses in patients with cognitive impairment include a psychiatric mood assessment and blood tests. The CXR shows no cardiopulmonary findings, while the head CT scan shows diffuse cerebral atrophy. The mental status exam score is 18/30, with deficits in attention, recall, orientation, and registration. The psychiatric mood assessment would assist rule out conditions such as depression, which also mimics cognitive impairment. The blood tests would also help identify the cause of cognitive impairment.  

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A (assessment)

Differential diagnoses:

1. Dementia. The primary diagnosis is dementia. Dementia is a chronic, progressive neurodegenerative condition that generally affects cognitive function and memory loss (Weintraub, 2022). The disorder is characterized by gradual decline of cognitive function that worsens with age. Its symptoms include forgetfulness, disorientation of time and place, and personality changes. The patient, in this case, presents with all the symptoms mentioned, thus considering the disorder as the primary diagnosis.
2. Mild cognitive impairment. According to Dunne et al. (2021), mild cognitive impairment is a disorder characterized by cognitive function changes, which are noticed but do not necessarily interfere with daily activities. The condition may be associated with age-related cognitive decline. Common symptoms include forgetting recent events/conversations and poor attention. Language, executive functions, and mood changes. In this case, the patient presents with memory loss of recent events, thus including the condition as a differential diagnosis. However, it is ruled out due to absence of mood changes, and the patient can manage daily activities.
3. Delirium. Delirium is an acute condition that develops rapidly over a short time and affects cognitive function. The condition is characterized by cognitive impairment, disorientation, hallucinations, inability to focus/sustain attention (Fong & Inouye, 2022). The patient, in this case, presents with disorientation to time and place, inability to focus and sustain attention, and cognitive impairment, therefore, delirium is a differential. The disorder is ruled out considering the patient’s condition does not have a sudden onset, and the patient reports no hallucinations.

P (plan)

After diagnosis, it is crucial to identify the therapeutic interventions that will work best for the client and the education required to reduce dementia progression and improve the quality of life. It is important to educate the patient and the caregiver on the disease, its symptoms and management. In this case, dementia cannot be cured, but its progression can be slowed, and symptoms managed. According to Kumar et al. (2022), medication therapy to manage dementia entails cholinesterase inhibitors such as galantamine and Partial N-Methyl D-Aspartate (NMDA) memantine. The patient should also be encouraged to continue adhering to the current medications to manage current conditions, including multivitamins for immunity support. A follow-up after four weeks will be required to assess the patient’s progress and determine if any changes should be made. The caregiver will be informed to consider getting the patient enrolled in art, speech and language therapy, and behavioral management to effectively manage dementia symptoms. Interacting with the case study, I have learned the essence of including health promotion and disease prevention in common patient education. For instance, for this patient, considering the age and past medical history, it is crucial to educate the patient on medication adherence, safety at home, and the necessary immunizations for this population/age. Therefore, the patient will receive holistic care, thus improving outcomes and the quality of life.      

References

By the 2019 American Geriatrics Society Beers Criteria® Update Expert Panel (2019). American Geriatrics Society 2019 Updated AGS Beers Criteria® for Potentially Inappropriate Medication Use in Older Adults. Journal of the American Geriatrics Society, 67(4), 674–694. https://doi.org/10.1111/jgs.15767  

Dunne, R. A., Aarsland, D., O’Brien, J. T., Ballard, C., Banerjee, S., Fox, N. C., Isaacs, J. D., Underwood, B. R., Perry, R. J., Chan, D., Dening, T., Thomas, A. J., Schryer, J., Jones, A. M., Evans, A. R., Alessi, C., Coulthard, E. J., Pickett, J., Elton, P., Jones, R. W. & Burns, A. (2021). Mild cognitive impairment: the Manchester consensus. Age and Ageing, 50(1), 72–80. https://doi.org/10.1093/ageing/afaa228

Fong, T. G., & Inouye, S. K. (2022). The inter-relationship between delirium and dementia: the importance of delirium prevention. Nature Reviews. Neurology, 18(10), 579–596. https://doi.org/10.1038/s41582-022-00698-7

Hemmy, L. S., Linskens, E. J., Silverman, P. C., Miller, M. A., Talley, K. M. C., Taylor, B. C., Ouellette, J. M., Greer, N. L., Wilt, T. J., Butler, M., & Fink, H. A. (2020). Brief Cognitive Tests for Distinguishing Clinical Alzheimer-Type Dementia from Mild Cognitive Impairment or Normal Cognition in Older Adults with Suspected Cognitive Impairment. Annals of internal medicine, 172(10), 678–687. https://doi.org/10.7326/M19-3889

Kumar, A., Sidhu, J., Goyal, A. &Tsao, J. W. (2022) Alzheimer Disease. In: StatPearls [Internet]. Retrieved from: https://www.ncbi.nlm.nih.gov/books/NBK499922/

Weintraub S. (2022). Neuropsychological Assessment in Dementia Diagnosis. Continuum (Minneapolis, Minn.), 28(3), 781–799. https://doi.org/10.1212/CON.0000000000001135  

Case Study:

Week 2 Case 2 (Alzheimer’s )

Dela Cruz, Dedic, Famador, Finefrock, Fritcher, Gallik, Gelegdorj, Go, Joseph, Kabir, Lopez

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Ms. Washington is a 67-year-old African American female who is brought to your office by her daughter with concerns about “forgetfulness.” She has lived with her daughter for 4 years now, and her daughter reports noticing she asks the same questions even after they have been answered. She even reports her mom getting lost in Walmart recently. Ms. Washington has lived with her daughter since losing her husband of 57 years about 4 years ago. Her daughter states her mother is a retired teacher and usually very astute but notices more forgetfulness.

According to Ms. Washington’s daughter, Angela, her mom has been demonstrating increased forgetfulness of more recent things but can easily recall historical moments and events. She also reports that sometimes her mom has difficulty “finding the right words” in a conversation and then will shift to an entirely different line of conversation. She also said her mother will “laugh off” things when she forgets important appointments and/or becomes upset or critical of others who try to point these things out.

Note: Be sure to review the Mini-Mental State Exam (MMSE) and how to interpret the results. Use the MMSE in the attached document to determine the patient’s MMSE score in the video. Make sure you document the patient’s score in your SOAP note document: Mental State Assessment Tests.

Ms. Washington is a 67-year-old female who is alert and cooperative with today’s clinical interview. Her eye contact is fair. Speech is clear and coherent but tangential at times. 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 is alert and oriented to person, partially oriented to place, but is disoriented to time and place. (She reported that she thought was headed to work but “wound up here,” referring to your office, at which point she begins to laugh it off.) She denies any falls or pain.

All other Review of System and Physical Exam findings are negative other than stated.

PMH: Hypertension, Hyperlipidemia, Osteoporosis

Allergies: Penicillin, Lisinopril

Medications:

Amlodipine 10mg daily

HCTZ 12.5mg daily

Multivitamin daily

Atorvastatin 40mg daily

Alendronate 70mg orally once a week

Social History: As stated in the Case Study

ROS: As stated in the Case study

Diagnostics/Assessments done:

CXR—no cardiopulmonary findings. WNL

CT head—diffuse Cerebral Atrophy

MMSE—Ms. Washington scores 18 out of 30 with primary deficits in orientation, registration, attention and calculation, and recall. The score suggests moderate dementia.

To prepare:

Review the case study provided by your Instructor. Reflect on the way the patient presented in the case, including whether the patient might be presenting with dementia, delirium, or depression.

Reflect on the patient’s symptoms and aspects of disorders that may be present. What distinct symptoms or factors would lead you to a diagnosis of dementia, delirium, or depression?

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 assessments results? How would you interpret and address the results of the Mini-Mental State Examination (MMSE)?

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 in or out. Explain you critical thinking process that led you to the primary diagnosis you selected. 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 healthcare 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 differentials diagnoses. Be sure they are current (no more than 5 years old) and support the treatment plan in following current standards of care. Follow APA 7th edition formatting.

Reminder: The College of Nursing requires that all papers submitted include a title page, introduction, summary, and references.

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NRNP_6540_Week2_Assignment_Rubric

NRNP_6540_Week2_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 pts Excellent 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 pts Good 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 pts Fair 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 pts Poor 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 pts Excellent 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 pts Good The response accurately documents the patient’s physical exam for pertinent systems. Diagnostic tests and their results are accurately documented. 8 to >7.0 pts Fair 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 pts Poor 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 pts Excellent 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 >19.0 pts Good 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. 19 to >18.0 pts Fair 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 pts Poor 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 pts Excellent 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 pts Good 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 pts Fair 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. 21 to >0 pts Poor 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 which 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 >9.0 pts Excellent 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 pts Good 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 pts Fair 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 pts Poor 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 pts Excellent 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 pts Good 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 pts Fair Paragraphs and sentences follow writing standards for flow, continuity, and clarity 60%–79% of the time. Purpose, introduction, and conclusion of the assignment is vague or off topic. 2 to >0 pts Poor 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 pts Excellent Uses correct grammar, spelling, and punctuation with no errors. 4 to >3.0 pts Good Contains a few (one or two) grammar, spelling, and punctuation errors. 3 to >2.0 pts Fair Contains several (three or four) grammar, spelling, and punctuation errors. 2 to >0 pts Poor Contains many (≥ five) 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/in-text citations, and reference list.	5 to >4.0 pts Excellent Uses correct APA format with no errors. 4 to >3.0 pts Good Contains a few (one or two) APA format errors. 3 to >2.0 pts Fair Contains several (three or four) APA format errors. 2 to >0 pts Poor Contains many (≥ five) APA format errors.	5 pts
Total Points: 100