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This assignment comes in 2 parts. Part 1 is a discussion of 300 words and 1 refe

March 5, 2024
Nursing

This assignment comes in 2 parts. Part 1 is a discussion of 300 words and 1 reference and 2 peer responses of 150 words each one and 1 reference. Part 2 is a SOAP note. Please follow the template attached and the instructions in the rubric.

Discussion

Week 1 Discussion

Instructions: Pick one case scenario to discuss in your initial post. For your peer responses, please reply to the case scenario you did not choose for the initial post. You are expected to respond to two different peers.

Case scenario 1: A 55-year-old male patient presented with a chief complaint of headache onset 7 days ago. He described the pain as severe, constant headache associated with a subjective fever of 102F, chills, and body malaise.

Write a brief SOAP note regarding this patient. Make sure to include your answers to these questions in your SOAP-Note.

  1. Subjective:
    • What other relevant questions should you ask regarding HPI?
    • What other medical history questions should you ask?
    • What other social history should you ask?
  2. Objective:
    • What are the common clinical symptoms that you will assess for this patient?
    • What other tests or procedures (Lab or Diagnostic) would you perform or order for this patient?
    • Complete the table to help you decide on differentials and final diagnoses.
      Compare CSF in Bacterial Versus Viral Meningitis
      Appearance Bacterial Viral
      Opening Pressure
      Cells
      Total Protein
      Glucose
      Culture
  3. Diagnosis:
    • What are the top 3 differential diagnoses you would consider for this patient, and what is your rationale?
    • What is the final diagnosis? How did you rule in/out the other diagnosis?
  4. Plan:
    • What is the gold standard treatment for this patient?

Case Scenario 2: A 60-year-old female who was taken to the ED via EMS due to a sudden onset of left-sided body weakness. The last known to be normal was 2 hours ago. The patient has PMH of HTN, HLD, and MI with 2 stents (2019). You are the provider in the ED and are assigned to manage this patient.

Write a brief H&P regarding this patient. Make sure to include your answers to these questions in your H&P.

  1. Subjective:
    • What pertinent questions will you ask the patient and/or the family?
    • What are the risk factors of this patient?
    • What other questions would you ask to help you differentiate the clinical signs and symptoms that mimic stroke?
  2. Objective:
    • Complete the table below to differentiate the clinical signs and symptoms of stroke depending on the affected area.
      Cerebral Vessel Involved Clinical Manifestations
      Middle cerebral artery (MCA)
      Anterior cerebral artery (ACA)
      Posterior cerebral artery (PCA)
      Vertebral and basilar arteries
      Cerebral strokes
      Lacunar strokes
    • What tests or procedures (Lab or Diagnostic) would you perform or order for this patient?
    • What other diagnostic tools would you use to help you diagnose the patient?
  3. Diagnosis:
    • What are the top 3 differential diagnoses you would consider for this patient, and what is your rationale?
  4. Plan:
    • What is the gold standard treatment for this patient?
    • What is your disposition? Admit vs. Discharge? Why?

Assignment

Instructions: Submit a problem-focused SOAP note for grading. You must use an actual patient from your clinical practicum who presents with one or more chief complaints.

Use this template Download this templatefor your SOAP note.

Use the current APA format to style your paper and cite your sources. Review the rubric for more information on how your assignment will be graded.

Rubric

Problem-focused SOAP Note Rubric

Problem-focused SOAP Note Rubric
Criteria Ratings Pts

This criterion is linked to a Learning OutcomeSubjective
15 to >13.0 pts

Accomplished

Symptom analysis is well organized, with C/C, OLDCART, pertinent negatives, and pertinent positives. All data needed to support the diagnosis & differential are present. Is complete, concise, relevant with no extraneous data.

 13 to >11.0 pts

Satisfactory

Symptom analysis well organized with C/C, OLDCART, pertinent negatives, and pertinent positives. Some extraneous data present and/or one minor data point missing.

 11 to >9.0 pts

Needs Improvement

Symptom analysis is not well organized. Data is missing. There is too much extraneous data and/or 2-3 minor data points missing.

 9 to >0 pts

Unsatisfactory

Symptom analysis is inadequate, is not organized. Objective or other data is mixed into the subjective data. Important data is missing.

15 pts

This criterion is linked to a Learning OutcomeObjective
15 to >13.0 pts

Accomplished

Complete, concise, well organized and well written and includes pertinent positive and pertinent negative physical findings. Organized by body system in list format. No extraneous data.

 13 to >11.0 pts

Satisfactory

All relevant exams were done thoroughly but extraneous exams were also done. Somewhat organized in list format.

 11 to >9.0 pts

Needs Improvement

Omitted important relevant exams and/or not in list format.

 9 to >0 pts

Unsatisfactory

Omitted important relevant exams and/or subjective data are included. Lacking organization.

15 pts

This criterion is linked to a Learning OutcomeAssessment
15 to >13.0 pts

Accomplished

Diagnosis and differential dx are correct with ICD code and supported by subjective and objective data.

 13 to >11.0 pts

Satisfactory

Diagnosis is correct with ICD codes and is supported by subjective and objective data, however the most accurate differential diagnosis not listed according to subjective and objective data.

 11 to >9.0 pts

Needs Improvement

Diagnosis is correct but either does not include ICD code or is missing two or more important differential diagnoses according to the subjective and objective data provided.

 9 to >0 pts

Unsatisfactory

Diagnosis is not correct, is not provided or is not reflective of the subjective and objective data provided.

15 pts

This criterion is linked to a Learning OutcomePlan
15 to >13.0 pts

Accomplished

Plan is organized, complete and evidence-based according to National Standards of Care. Addresses each diagnosis and is individualized to the specific patient and includes medication teaching and all 5 components: (Dx plan, Tx plan, patient education, referral/follow-up, health maintenance).

 13 to >11.0 pts

Satisfactory

Plan is organized, complete and evidence-based according to National Standards of Care. Addresses each diagnosis and is individualized to the specific patient and includes medication teaching but may be missing 1-2 minor points.

 11 to >9.0 pts

Needs Improvement

Plan is less organized and not based on evidence according to National Standards of Care. Does not address each diagnosis or may not be individualized to the specific patient. Missing medication teaching or one of the 5 components.

 9 to >0 pts

Unsatisfactory

No Plan provided or is not organized. Does not address all diagnoses identified and/or does not include all 5 components of plan, including medication teaching.

15 pts

Total Points: 60

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