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Focused Note Case Study Assignment Discussion Paper

Focused Note Case Study Assignment Discussion Paper

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Case Study/SOAP Note

Patient Information:

S., 38, Female, Not specified in the case

S.

CC (chief complaint): Susan presents to discuss contraceptive options.

HPI: Susan, a 38-year-old female, presents for contraceptive options. History includes exercise-induced asthma, migraines, and IBS. She’s had inconsistent use of birth control and recently used natural family planning, resulting in unexpected pregnancies. Menstrual cycles are regular but heavy. The last gynecological exam was a year ago, with normal results. Migraines occur before periods or when stressed, managed with Excedrin Migraine. She’s interested in a pill for fewer periods and plans to set reminders. No significant changes in medications or allergies were reported. Family and social history are unremarkable, and she has five children from previous pregnancies. Focused Note Case Study Assignment Discussion Paper

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Current Medications: Vitamin C

Allergies: No known allergies reported

PMHx: Susan has a history of exercise-induced asthma, irritable bowel syndrome (IBS), and migraines.

Soc & Substance Hx: Susan denies tobacco, alcohol, and recreational drug use. No reported vaping. She has no current or previous use of contraceptives, except for natural family planning.

Fam Hx: Both Susan’s maternal grandparents and grandmother are still living, with her mother’s having COPD. The reason for the death of her paternal grandparents was an automobile accident. Her father has a history of basal cell skin cancer, while her mother currently suffers from osteopenia and fibromyalgia. Both Susan’s younger brother and elder sister don’t seem to have any health issues.

Surgical Hx: Susan’s surgical history is notable only for tonsillectomy as a child.

Mental Hx: Not indicated

Violence Hx: Not mentioned

Reproductive Hx: Susan is gravida 5, para 5. Her menstrual cycles are regular, occurring every 28-32 days and lasting 5-8 days. She experiences heavy bleeding, requiring frequent tampon and pad changes. Her last gynecological exam, including pap, HPV, and GC/CT cultures, was one year ago, with normal results. Susan has used birth control pills inconsistently, discontinued the patch for reasons she doesn’t remember, and recently relied on natural family planning, resulting in unexpected pregnancies. She reports migraines occurring before periods or when stressed, with accompanying vision changes in her right eye. Migraines are managed with Excedrin Migraine. Susan expresses interest in a contraceptive pill that allows her to have only four periods a year and plans to set reminders for daily pill intake.

Additional information that would enhance the case study includes: Focused Note Case Study Assignment Discussion Paper

  1. Detailed Menstrual History: Specifics about menstrual symptoms, associated pain, and changes over time.
  2. Migraine Triggers: Identifying specific triggers contributing to migraines.
  3. Contraceptive History: More details on previous contraceptive methods, reasons for discontinuation, and experiences.
  4. Psychosocial Factors: Exploring stressors, lifestyle factors, and emotional well-being.
  5. Current Medications: A comprehensive list of current medications, including over-the-counter supplements.
  6. Patient’s Future Family Planning Goals: Understanding long-term family planning preferences.

Top of Form

ROS:

GENERAL: Susan denies fatigue, weight loss, or fever. No recent or unexplained changes in appetite or sleep patterns.

Constitutional: No chills or night sweats reported. No recent changes in energy levels or overall well-being.

Head: Denies headaches other than migraines mentioned earlier. No head trauma, dizziness, or light-headedness.

Eyes: Vision changes associated with migraines mentioned earlier. No recent changes in vision, double vision, or eye pain. No history of eye surgery or corrective lenses.

Ears, Nose, Throat (ENT): No hearing loss, earaches, or tinnitus. No nasal congestion, sinus pain, or frequent nosebleeds. No sore throat or difficulty swallowing.

CARDIOVASCULAR: No chest pain or discomfort. No palpitations or irregular heartbeats. No swelling of ankles or lower extremities.

RESPIRATORY: No shortness of breath, cough, or wheezing. No history of respiratory infections or chronic respiratory conditions.

GASTROINTESTINAL: Denies nausea, vomiting, or abdominal pain. No changes in bowel habits or blood in stool. No history of acid reflux or heartburn.

GENITOURINARY: No dysuria, urgency, frequency, or hematuria reported. No history of urinary tract infections. Reports a 1st-degree cystocele, otherwise, denies pelvic pain.

MUSCULOSKELETAL: No joint pain, stiffness, or swelling. No muscle weakness or limitations in range of motion. Reports exercise-induced asthma.

INTEGUMENTARY: No rashes, lesions, or changes in moles reported. History of basal cell skin cancer in the father.

NEUROLOGICAL: Reports migraines associated with vision changes. No seizures, tremors, or weakness.

PSYCHIATRIC: Denies anxiety, depression, or mood changes. No history of psychiatric disorders or hospitalizations.

ENDOCRINE: No excessive thirst or hunger. No heat or cold intolerance.

HEMATOLOGIC/LYMPHATIC: No history of easy bruising or bleeding. No swollen lymph nodes reported.

ALLERGIC/IMMUNOLOGIC: No known drug allergies.

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Physical Exam:

General:

Susan does not seem to be in any immediate pain and seems well-fed.

Head:

Normocephalic and atraumatic.

Hair distribution appears normal.

Eyes:

Pupils are equal and reactive to light.

Extraocular movements are intact.

No conjunctival injection or discharge.

Fundoscopic exam reveals no abnormalities.

Ears, Nose, Throat (ENT):

Tympanic membranes are intact with no signs of inflammation or effusion.

Nasal mucosa is pink and moist, without congestion.

Oropharynx is clear with no erythema or exudate.

Cardiovascular:

Heart sounds are regular, no murmurs, gallops, or rubs.

Radial and brachial pulses are palpable and symmetric.

Respiratory:

Respiratory rate is within normal limits.

Clear breath sounds bilaterally, no wheezing or crackles.

Gastrointestinal:

Abdomen is soft, non-tender, and without palpable masses.

Bowel sounds present in all quadrants.

1st-degree cystocele noted on visual inspection.

Genitourinary:

External genitalia appear normal.

Cervix is firm, smooth, and parous, with no cervical motion tenderness.

Uterus is retroverted, mobile, non-tender, and approximately 10 cm.

No masses or tenderness in the adnexal regions.

Musculoskeletal:

No joint deformities, swelling, or tenderness noted.

Normal range of motion in major joints.

Integumentary:

No suspicious moles or lesions observed.

No signs of rashes or skin abnormalities.

Neurological:

Oriented to time, place, and person.

Cranial nerves II-XII intact.

No focal motor or sensory deficits.

Psychiatric:

Cooperative and interactive during the examination.

Affect appears appropriate to the conversation.

A.

Primary Diagnosis: Menstrual Migraines

Susan exhibits symptoms of menstrual migraines, which are unique to the menstrual cycle. These include headaches before her period and changes in her right eye’s vision. These migraines, identified by ICHD-3, most likely have hormonal causes. Susan’s Excedrin usage Acute migraine treatment is compatible with migraine; nevertheless, care must be taken to prevent medication overuse headaches. According to Vetvik and MacGregor (2021), menstrual migraine management entails modifying one’s lifestyle, figuring out causes, and receiving acute care. Contraceptives are one type of hormonal intervention that may regulate swings and stop episodes.

Differential Diagnosis 1: Dysmenorrhea

Given Susan’s excessive bleeding and need for super tampons, dysmenorrhea is considered. An all-encompassing strategy is essential when coexisting with migraines. Examining menstruation patterns for signs of severe bleeding is advised by ACOG. According to Ferries-Rowe et al. (2020), management strategies include pain alleviation, lifestyle modifications, and hormonal therapies where needed.

Differential Diagnosis 2: Polycystic Ovary Syndrome (PCOS)

Given Susan’s past, PCOS may be a possibility, given her erratic menstrual cycles and hormone abnormalities that exacerbate headaches. Hormonal tests and pelvic ultrasonography are diagnostic tools. Interventions, which may include hormonal therapy, lifestyle modifications, and fertility control, are guided by a thorough assessment (Joham et al., 2022)Focused Note Case Study Assignment Discussion Paper.

Differential Diagnosis 3: Contraceptive-related Side Effects

Contraceptive history prompts consideration of side effects influencing migraines. Understanding Susan’s preferences is crucial for counseling. Discussion about extended-cycle pills aligns with her interest in reducing menstruation frequency. Assessing adherence guides the selection of a contraceptive aligning with lifestyle and health goals (Marshall & Von Hippel, 2020) Focused Note Case Study Assignment Discussion Paper

  1. Menstrual Migraines:

Diagnostic Studies: Initiate a headache diary.

Therapeutic Interventions: Lifestyle modifications, stress management, and acute medications.

Education: Provide information on triggers and adherence.

Disposition: Follow up to assess treatment efficacy.

  1. Dysmenorrhea:

Diagnostic Studies: Evaluate menstrual patterns; consider imaging if needed.

Therapeutic Interventions: Pain relief, lifestyle changes, and hormonal interventions. Focused Note Case Study Assignment Discussion Paper

Education: Menstrual health education.

Disposition: Schedule regular follow-ups.

  1. PCOS:

Diagnostic Studies: Pelvic ultrasound, hormonal assays.

Therapeutic Interventions: Lifestyle changes, hormonal therapies, fertility management.

Education: PCOS education.

Disposition: Regular follow-ups for monitoring.

  1. Contraceptive-related Side Effects:

Diagnostic Studies: Review contraceptive history.

Therapeutic Interventions: Discuss alternative contraceptives.

Education: Contraceptive education.

Disposition: Follow up to assess adherence.

Reflection

I support the preceptor’s all-encompassing strategy incorporating specialized interventions and education. This case reaffirmed the significance of patient preferences in contraceptive counselling. The importance of cultural factors in healthcare decisions and the necessity of preventive measures in standard care are among the lessons to be learned. In subsequent cases, I would incorporate proactive health promotion and place more emphasis on cultural sensitivity. Effective patient care continues to depend on ongoing education and strategy adaptation to meet the needs of each patient.

References

Joham, A. E., Norman, R. J., Stener-Victorin, E., Legro, R. S., Franks, S., Moran, L. J., … & Teede, H. J. (2022). Polycystic ovary syndrome. The Lancet Diabetes & Endocrinology, 10(9), 668-680. https://doi.org/10.1016/s2213-8587(22)00163-2

Ferries-Rowe, E., Corey, E., & Archer, J. S. (2020). Primary dysmenorrhea: diagnosis and therapy. Obstetrics & Gynecology, 136(5), 1047-1058. https://doi.org/10.1097/aog.0000000000004096

Marshall, C., & Von Hippel, C. (2020, October). User strategies for navigating contraceptive side effects: Data from an online community. In APHA’s 2020 VIRTUAL Annual Meeting and Expo (Oct. 24-28). APHA.

Vetvik, K. G., & MacGregor, E. A. (2021). Menstrual migraine: a distinct disorder needing greater recognition. The Lancet Neurology, 20(4), 304-315. https://doi.org/10.1016/s1474-4422(20)30482-8 Focused Note Case Study Assignment Discussion Paper

To prepare:

  • By Day 1 of this week, you will be assigned to a specific case study scenario for this Discussion. Please see the “Course Announcements” section of the classroom for your case study assignment from your Instructor.
  • Review the Learning Resources for this week and pay close attention to the media program related to the basic microscope skills. Also, consider re-reviewing the media programs found in Week 1 Learning Resources.
  • Carefully review the clinical guideline resources specific to your assigned case study.
  • Use the Focused SOAP Note Template found in the Learning Resources to support Discussion. Complete a FOCUSED SOAP note and critically analyze this and focus your attention on the diagnostic tests. Please post your SOAP note. This will help you develop your differential diagnosis and additional questions

Please post your FOCUSED SOAP NOTE with your differential diagnosis. Include the additional questions (additional questions ONLY related to the HPI/CC) you would ask the patient. Be sure to include an explanation of the tests you might recommend, ruling out any other issues or concerns and include your rationale. Be specific and provide examples. Use your Learning Resources and/or evidence from the literature to support your explanations. Your differential diagnosis, additional questions, additional diagnostic tests and rationales are what this assignment and grading is focused on. Your critical thinking for this assignment

See the assignment tab for the week #3 discussion and post your FOCUSED SOAP NOTE with your differential diagnosis. Include the additional questions (additional questions ONLY related to the HPI/CC) you would ask the patient. Be sure to include an explanation of the tests you might recommend, ruling out any other issues or concerns and include your rationale. Be specific and provide examples. Use your Learning Resources and/or evidence from the literature to support your explanations. Your differential diagnosis, additional questions, additional diagnostic tests and rationales are what this assignment and grading is focused on. Your critical thinking for this assignment. Review your colleagues’ initial responses. Focused Note Case Study Assignment Discussion Paper

Case Study Scenario

Susan Spencer is a 38-year-old G5 P5 LC 6 presenting to your clinic today to discuss contraceptive options.  She states that she is not interested in having more children but her new partner has never fathered a child. Her medical history is remarkable for exercise-induced asthma, migraines, and IBS. Her surgical history is remarkable only for tonsils as a child. Her social history is negative for alcohol, tobacco, and recreational drugs.  She has no known drug allergies and takes only vitamin C. Hospitalizations were only for childbirth. Family history reveals that her maternal grandmother is alive with dementia, while her maternal grandfather is alive with COPD. Her paternal grandparents are both deceased due to an automobile accident. Her mother is alive with osteopenia and fibromyalgia, and her dad is alive with a history of skin cancer (basal cell). Susan has one older sister with no medical problems and one younger brother with no reported medical problems.

Height 5’ 7” Weight 148 (BMI 23.1), BP 118/72 P 68

  • HEENT:  WNL
  • Neck: supple without adenopathy
  • Lungs/CV: WNL
  • Breast: soft, fibrocystic changes bilaterally, without masses, dimpling, or discharge
  • Abd: soft, +BS, no tenderness
  • VVBSU: WNL, except 1st-degree cystocele
  • Cervix: firm, smooth, parous, without CMT
  • Uterus: RV, mobile, non-tender, approximately 10 cm,
  • Adnexa: without masses or tenderness  Focused Note Case Study Assignment Discussion Paper

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QUESTION:

What other information do you need for this case study?

Further information:

Susan relates to you that she has used birth control pills before but “would keep messing them up.”  After that, she switched to the patch, which she found worked well but discontinued use for reasons she does not remember. After that, she used natural family planning but still conceived her last two children unexpectedly.  She has had three partners in the last 12 months and has been with her current partner for the previous two months. She believes that he is “the one.”

Susan relates that her cycles come every 28-32 days, for 5-8 days, and on her heaviest day she must use a super tampon every hour and get up to change her pad 2-3 times at night. Her last GYN exam was one year ago and she shows you a copy of the results on her patient portal. The results for the pap were NILM, and HPV negative, and her cultures for GC/CT were negative.

In further questioning, you ask her about her migraines. She shares that these migraines occur just before her period, or when she’s stressed, and are preceded by a vision change in her right eye. She takes Excedrin Migraine for them and rests in a dark room until the migraine is done.

She has heard about a pill where she will only get her period four times a year and feels now that she’s older she can remember to take the pill daily and plans on putting a reminder in her phone.

QUESTIONS:

  • What are your next steps/considerations?
  • What teaching should you do?
  • What methods are appropriate for Susan?

References: 

Schuiling, K. D. (2017). Women’s gynecologic health (3rd ed.). Burlington, MA: Jones and Bartlett Learning.

  • Chapter 11

Please use the Walden Library to research options and care for this patient. The resources should be from the last 5 years and be scholarly. NO WEB SEARCHES or public education sites may be used for citations in this course. This means: American Cancer Society, Web MD, Google etc. Our patients have access to this information and the research you do should be more advanced than a simple web search that anyone can do. Focused Note Case Study Assignment Discussion Paper

Class Resources:

  • Schuiling, K. D., & Likis, F. E. (2022). Gynecologic health care(4th ed.). Jones and Bartlett Learning.
    • Chapter 10, “Women’s Health After Bariatric Surgery” (pp. 165 – 171)
  • Agency for Healthcare Research and Quality (AHRQ). Intimate partner violence screening: Fact sheet and resourcesLinks to an external site.. https://www.ahrq.gov/ncepcr/tools/healthier-pregnancy/fact-sheets/partner-violence.html
  • Fanslow, J., Wise, M. R., & Marriott, J. (2019). Intimate partner violence and women’s reproductive healthLinks to an external site.. Obstetrics, Gynaecology & Reproductive Medicine, 29(12), 342–350. https://go.openathens.net/redirector/waldenu.edu?url=https://doi.org/10.1016/j.ogrm.2019.09.003
  • Lockwood, C. J. (2019). Key points for today’s ‘well-woman’ exam: A guide for ob/gynsLinks to an external site.. Contemporary OB/GYN, 64(1), 23–29. https://search.ebscohost.com/login.aspx?direct=true&db=rzh&AN=134229869&site=ehost-live&scope=site&authtype=shib&custid=s6527200 Focused Note Case Study Assignment Discussion Paper

CLINICAL GUIDELINE RESOURCES

  • American College of Obstetricians and Gynecologists (ACOG)Links to an external site.. (2020).  https://www.acog.org/
  • American Nurses Association (ANA)Links to an external site.. (n.d.). https://www.nursingworld.org/
  • Centers for Disease Control and Prevention. (CDC)Links to an external site.. (n.d.). https://www.cdc.gov/
  • HealthyPeople 2030. (2020). Healthy People 2030 FrameworkLinks to an external site.. https://www.healthypeople.gov/2020/About-Healthy-People/Development-Healthy-People-2030/Framework
  • The American Association of Nurse Practitioners (AANP)Links to an external site.. What’s happening at your association. (2020). https://www.aanp.org/
  • Document:Focused SOAP Note Template Download Focused SOAP Note Template(Word document) Focused Note Case Study Assignment Discussion Paper

RUBRIC

PRAC_6552_Week3_Assignment2_Rubric

PRAC_6552_Week3_Assignment2_Rubric
Criteria Ratings Pts
This criterion is linked to a Learning OutcomeCreate documentation in the Focused SOAP Note Template about the patient you selected. In the Subjective section, provide: • Chief complaint• History of present illness (HPI) • Current medications• Allergies• Patient medical history (PMHx), including immunization status, social and substance history, family history, past surgical procedures, mental health, safety concerns, reproductive history• Review of systems
10 to >8.0 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.

8 to >7.0 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.

7 to >6.0 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.

6 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. 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 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.

8 to >7.0 pts

Good

The response accurately documents the patient’s physical exam for pertinent systems. Diagnostic tests and their results are accurately documented.

7 to >6.0 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.

6 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 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 >22.0 pts

Excellent

The response lists 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.

22 to >19.0 pts

Good

The response lists 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 >17.0 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.

17 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.• Reflections on the case describing insights or lessons learned. • A discussion related to health promotion and disease prevention taking into consideration patient factors, PMH, and other risk factors.
30 to >26.0 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. Reflections on the case demonstrate strong critical thinking and synthesis of ideas. A thorough and accurate disucssion of health promotion and disease prevention related to the case is provided.

26 to >23.0 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. Reflections on the case demonstrate critical thinking. An accurate disucssion of health promotion and disease prevention related to the case is provided.

23 to >20.0 pts

Fair

The response somewhat vaguely or inaccurately outlines a treatment plan for the patient. Reflections on the case demonstrate adequate understanding of course topics. The discussion on health promotion and disease prevention related to the case is somewhat vague or contains innaccuracies.

20 to >0 pts

Poor

The response does not address all diagnoses or is missing elements of the treatment plan. Reflections on the case are vague or missing. The discussion on health promotion and disease prevention related to the case is vague, innaccurate, 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 relates to this case to support your diagnostics and differentials 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 >8.0 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.

8 to >7.0 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.

7 to >6.0 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.

6 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 >3.5 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.

3.5 to >3.0 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.

3 to >0 pts

Poor

Paragraphs and sentences follow writing standards for flow, continuity, and clarity less than 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 >3.5 pts

Good

Contains a few (1 or 2) grammar, spelling, and punctuation errors.

3.5 to >3.0 pts

Fair

Contains several (3 or 4) grammar, spelling, and punctuation errors.

3 to >0 pts

Poor

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/in-text citations, and reference list.
5 to >4.0 pts

Excellent

Uses correct APA format with no errors.

4 to >3.5 pts

Good

Contains a few (1 or 2) APA format errors.

3.5 to >3.0 pts

Fair

Contains several (3 or 4) APA format errors.

3 to >0 pts

Poor

Contains many (≥ 5) APA format errors.

5 pts
Total Points: 100

Episodic/Focused SOAP Note Template

 Patient Information:

Initials, Age, Sex, Race

S.

CC (chief complaint): This is a brief statement identifying why the patient is here in the patient’s own words, for instance, “headache,” not “bad headache for 3 days.”

HPI: This is the symptom analysis section of your note. Thorough documentation in this section is essential for patient care, coding, and billing analysis. Paint a picture of what is wrong with the patient. Use LOCATES Mnemonic to complete your HPI. You need to start every HPI with age, race, and gender (e.g., 34-year-old African American female). You must include the seven attributes of each principal symptom in paragraph form, not a list. If the CC was “headache,” the LOCATES for the HPI might look like the following example:

Location: head

Onset: 3 days ago

Character: pounding, pressure around the eyes and temples

Associated signs and symptoms: nausea, vomiting, photophobia, phonophobia

Timing: after being on the computer all day at work

Exacerbating/relieving factors: light bothers eyes, Naproxen makes it tolerable but not completely better Focused Note Case Study Assignment Discussion Paper

Severity: 7/10 pain scale

Current Medications: Include dosage, frequency, length of time used, and reason for use. Also include over-the-counter (OTC) or homeopathic products.

Allergies: Include medication, food, and environmental allergies separately. Provide a description of what the allergy is (e.g., angioedema, anaphylaxis). This will help determine a true reaction versus intolerance.

PMHx: Include immunization status (note date of last tetanus for all adults), past major illnesses, and surgeries. Depending on the CC, more info is sometimes needed.

Soc & Substance Hx: Include occupation and major hobbies, family status, vaping, tobacco and alcohol use (previous and current use, how many times a day, how many years), and any other pertinent data. Always add some health promotion questions here, such as whether they use seat belts all the time or whether they have working smoke detectors in the house, the condition of the living environment, text/cell phone use while driving, and support systems available.

Fam Hx: Illnesses with possible genetic predisposition, contagious illnesses, or chronic illnesses. The reason for death of any deceased first-degree relatives should be included. Include parents, grandparents, siblings, and children. Include grandchildren if pertinent.

Surgical Hx: Prior surgical procedures.

Mental Hx: Diagnosis and treatment. Current concerns: (Anxiety and/or depression). History of self-harm practices and/or suicidal or homicidal ideation.

Violence Hx: Concern or issues about safety (personal, home, community, sexual—current and historical).

Reproductive Hx: Menstrual history (date of last menstrual period [LMP]), pregnant (gravida and Parity), nursing/lactating (yes or no), contraceptive use (method used), types of intercourse (oral, anal, vaginal, other), gender sexual preference, and any sexual concerns.

ROS: This covers all body systems that may help you include or rule out a differential diagnosis. You should list each system as follows: General: Head: EENT: and so forth. You should list these in bullet format and document the systems in order from head to toe.

Example of Complete ROS: Focused Note Case Study Assignment Discussion Paper

GENERAL: No weight loss, fever, chills, weakness, or fatigue.

HEENT: Eyes: No 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: No chest pain, chest pressure, or chest discomfort. No palpitations or edema.

RESPIRATORY: No shortness of breath, cough, or sputum.

GASTROINTESTINAL: No anorexia, nausea, vomiting, or diarrhea. No abdominal pain or blood.

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

MUSCULOSKELETAL: No muscle pain, back pain, joint pain, or stiffness.

HEMATOLOGIC: No anemia, bleeding, or bruising.

LYMPHATICS: No enlarged nodes. No history of splenectomy.

PSYCHIATRIC: No history of depression or anxiety.

ENDOCRINOLOGIC: No reports of sweating or cold or heat intolerance. No polyuria or polydipsia.

GENITOURINARY/REPRODUCTIVE: Burning on urination. Pregnancy. LMP: MM/DD/YYYY. Breast-lumps, pain, discharge? No reports of vaginal discharge, pain?. sexually active?

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

O.

Physical exam: From head to toe, include what you see, hear, and feel when conducting your physical exam. You only need to examine the systems that are pertinent to the CC, HPI, and history. Do not use “WNL” or “normal.” You must describe what you see. Always document in head-to-toe format (i.e., General: Head: EENT:)Focused Note Case Study Assignment Discussion Paper.

Diagnostic results: Include any labs, x-rays, or other diagnostics that are needed to develop the differential diagnoses (support with evidenced and guidelines).

A.

Primay and Differential Diagnoses (list a minimum of 3 differential diagnoses). Your primary or presumptive diagnosis should be at the top of the list. For each diagnosis, provide supportive documentation with evidence-based guidelines.

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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. Each diagnosis or condition documented in the assessment should be addressed in the plan. The details of the plan should follow an orderly manner. Also included in this section is the reflection. The student should reflect on this case and discuss whether or not they agree with their preceptor’s treatment of the patient and why or why not. What did they learn from this case? What would they do differently?

Also include in your reflection a discussion related to health promotion and disease prevention, taking into consideration patient factors (e.g., age, ethnic group), PMH, and other risk factors (e.g., socioeconomic, cultural background).

References

You are required to include 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 to use correct APA 7th edition formatting. Focused Note Case Study Assignment Discussion Paper

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