[Solved] Nursing unit 4 assignment

Assignment Prompt & Instructions

see attached- i am having trouble accessing the rubric..as soon as i get it, i will attach it.

– a month ago

**files (2)**

– ## 674unit4assignment.docx

– ## MSN_SOAP_Note_Template_2402C1.docx

**## 674unit4assignment.docx**

**Case Study 4:** Mrs. Julie presents with mood symptoms and is at risk for suicide. Refer to assignment directions in Tab #2 for further information.

Your writing assignment should:

· follow the conventions of Standard English (correct grammar, punctuation, etc.);

· be well ordered, logical, and unified, as well as original and insightful;

· display superior content, organization, style, and mechanics; and;

· use APA formatting and citation style.

**Case Study Scenario:**

Mrs. Julie is a widowed 77-year-old retired bank teller who has been brought to the emergency department by her son and daughter as they have been worried about her mood for the past couple of months. This afternoon, when they were both over for a visit, hoping to convince their mom to go out to dinner with the family, Mrs. Julie admitted to them that she felt so terrible that she wanted to die. Her family became very concerned and decided to bring her to the hospital for assessment.

Mrs. Julie was assessed by the emergency physician, who did not feel there were any acute systemic medical illnesses and referred her to the emergency psychiatric team to evaluate her suicidal risk. During her assessment with the on-call psychiatrist, Mrs. Julie admits that she has been feeling lonely and down for about the past 3 months. Her husband of 53 years had passed away 6 months ago suddenly from a massive heart attack. Mrs. Julie thought she managed quite well initially. Even though she was sad that he was gone, she could still do what was needed at the time — making funeral arrangements and dealing with the lawyer and all the necessary paperwork. Then, about 3 months ago, it all just “hit” her. She was feeling very lonely, particularly at nighttime when she would lie in bed, staring at the ceiling and unable to fall asleep. She continued to feel worse as time passed, walking around the house aimlessly during the daytime, looking for something to do, and eventually ending up sleeping on the couch, so she would no longer have to think. She became increasingly withdrawn and stopped calling her family and friends as she did not feel like talking to anyone.

Mrs. Julie was still keeping up with her personal hygiene but stopped doing housework about a month ago. In the past 2 weeks, she has not felt much like cooking and is just eating crackers and peanut butter. In the past 2 days, she has thought that it would be easier if she could join her husband in death and be at peace.

Before the arrival of her family at her house today, she was looking at her medications and thinking it would be nice to take all of her “sleeping pills” at once. She became very scared by her thoughts. When her children arrived, she told them what she had been thinking. Currently, while she has no plans to kill herself, she is afraid those thoughts would come back when she goes home alone as she does not see any reason to live.

Mrs. Julie states that she has never felt like this before in her life. She has always been a very upbeat and energetic person. While she may have gone through some difficult periods in the past, she states that she has always managed to get through these times without help. She has never needed to see a psychiatrist for any reason. She denies ever drinking alcohol excessively and denies the use of any illicit drugs.

Medical history revealed that she had a left-side stroke about 10 years ago with full recovery. She has hypertension and hyperlipidemia; these conditions are treated and controlled. Her primary care physician recently told her she is “borderline diabetic.” She also had a significant gastrointestinal bleed about 5 years ago due to a peptic ulcer. She had a remote tonsillectomy and an appendectomy about 15 years ago. Mrs. Julie has a younger sister who went through a “nervous breakdown” after a miscarriage. Mrs. Julie thinks her sister may have been on medication for her “nerves” for a while but does not know of her specific diagnosis or the name of the medication.

Mrs. Julie’s medications included rosuvastatin 10 mg daily, metoprolol 12.5 mg twice daily, aspirin 81 mg daily, pantoprazole 40 mg daily, clopidogrel 75 mg daily, and lorazepam 1 mg every 2 hour as needed (started by her primary care physician after her husband passed away; she takes it about three times a week). Laboratory investigations ordered by the emergency physician included CBC, electrolytes, creatinine (Cr), estimated glomerular filtration rate (eGFR), aspartate aminotransferase (AST), gamma-glutamyl transferase (GGT), alanine aminotransferase (ALT), random glucose, and a urinalysis. Other than a slightly high random glucose of 13.4 mmol/L (241.2 mg/dl), all other blood test results were within normal limits.

Use the SOAP note template to complete the documentation with the information provided.

· Formulate appropriate diagnoses and design an appropriate treatment plan.

· Explain what further information you will explore to aid in forming an accurate diagnosis.

· What treatment management would you recommended for this patient?

· How would you predict Julie’s response to treatment?

· Discuss clinical judgment and interventions to enhance the client’s safety.

[**Unit 4 Assignment Grading Rubric**](https://purdueglobal.brightspace.com/d2l/common/dialogs/quickLink/quickLink.d2l?ou=398929&type=rubric&rCode=kaplan-3651864)

**## MSN_SOAP_Note_Template_2402C1.docx**

| | | |
| — | — | — |
| **Name:** | **Pt. Encounter Number:** |
| **Date:** | **Age:** | **Sex:** |
| **SUBJECTIVE** |
| **CC:**<br>_Reason given by the patient for seeking medical care “in quotes”_ |
| **HPI:**<br>_Describe the course of the patient’s illness, including when it began, character of symptoms, location where the symptoms began, aggravating or alleviating factors, pertinent positives and negatives, other related diseases, past illnesses, and surgeries or past diagnostic testing related to the present illness._ |
| **Medications:** _(List with reason for med )_ |
| **Allergies:** _(List with reaction)_<br>**Medication Intolerances:** |
| **Past Medical History:**<br>**Chronic Illnesses/Major traumas**<br>**Hospitalizations/Surgeries**<br>_“Have you ever been told that you have  diabetes, HTN, peptic ulcer disease, asthma, lung disease, heart disease, cancer, TB, thyroid problems, kidney problems, or psychiatric diagnosis?”_ |
| **Family History**<br>_Does your mother, father, or siblings have any medical or psychiatric illnesses?  Is anyone diagnosed with: lung disease, heart disease, HTN, cancer, TB, DM, or kidney disease?_ |
| **Social History**<br>_Education level, occupational history, current living situation/partner/marital status, substance use/abuse, ETOH, tobacco, and marijuana.  Safety status_ |
| **ROS Student to ask each of these questions to the patient: “Have you had any…..”** |
| **General**<br>_Weight change, fatigue, fever, chills, night sweats,  and energy level_ | **Cardiovascular**<br>_Chest pain, palpitations, PND, orthopnea, and edema_ |
| **Skin**<br>_Delayed healing, rashes, bruising, bleeding or skin discolorations, and any changes in lesions or moles_ | **Respiratory**<br>_Cough, wheezing, hemoptysis, dyspnea, pneumonia hx, and TB_ |
| **Eyes**<br>_Corrective lenses, blurring, and visual changes of any kind_ | **Gastrointestinal**<br>_Abdominal pain, N/V/D, constipation, hepatitis, hemorrhoids, eating disorders, ulcers, and black, tarry stools_ |
| **Ears**<br>_Ear pain, hearing loss, ringing in ears, and discharge_ | **Genitourinary/Gynecological**<br>_Urgency, frequency burning, change in color of urine._<br>_Contraception, sexual activity, STDs_<br>_Female: last pap, breast, mammo, menstrual complaints, vaginal discharge, pregnancy hx_<br>_Male: prostate, PSA, urinary complaints_ |
| **Nose/Mouth/Throat**<br>_Sinus problems, dysphagia, nose bleeds or discharge, dental disease, hoarseness, and throat pain_ | **Musculoskeletal**<br>_Back pain, joint swelling, stiffness or pain, fracture hx, and osteoporosis_ |
| **Breast**<br>_SBE, lumps, bumps, or changes_ | **Neurological**<br>_Syncope, seizures, transient paralysis, weakness, paresthesias, and black-out spells_ |
| **Heme/Lymph/Endo**<br>_HIV status, bruising, blood transfusion hx, night sweats, swollen glands, increase thirst, increase hunger, and cold or heat intolerance_ | **Psychiatric**<br>_Depression, anxiety, sleeping difficulties, suicidal ideation/attempts, and previous dx_ |
| **OBJECTIVE** |
| **Weight         BMI** | **Temp** | **BP** |
| **Height** | **Pulse** | **Resp** |
| **General Appearance**<br>_Healthy-appearing adult female in no acute distress. Alert and oriented; answers questions appropriately. Slightly somber affect at first and then brighter later._ |
| **Skin**<br>_Skin is brown, warm, dry, clean, and intact. No rashes or lesions noted._ |
| **HEENT**<br>_Head is normocephalic, atraumatic, and without lesions; hair evenly distributed. Eyes:  PERRLA. EOMs intact. No conjunctival or scleral injection. Ears: Canals patent. Bilateral TMs pearly gray with positive light reflex; landmarks easily visualized. Nose: Nasal mucosa pink; normal turbinates. No septal deviation. Neck: Supple. Full ROM; no cervical lymphadenopathy; no occipital nodes. No thyromegaly or nodules. Oral mucosa, pink and moist. Pharynx is nonerythematous and without exudate. Teeth are in good repair_. |
| **Cardiovascular**<br>_S1, S2 with regular rate and rhythm. No extra sounds, clicks, rubs, or murmurs. Capillary refills two seconds. Pulses 3+ throughout. No edema._ |
| **Respiratory**<br>_Symmetric chest wall. Respirations regular and easy; lungs clear to auscultation bilaterally_. |
| **Gastrointestinal**<br>_Abdomen obese; BS active in all the four quadrants. Abdomen soft, nontender. No hepatosplenomegaly_. |
| **Breast**<br>_Breast is free from masses or tenderness, no discharge, no dimpling, wrinkling, or discoloration of the skin_. |
| **Genitourinary**<br>_Bladder is nondistended; no CVA tenderness. External genitalia reveals coarse pubic hair in normal distribution; skin color is consistent with general pigmentation. No vulvar lesions noted. Well estrogenized. A small speculum was inserted; vaginal walls are pink and well rugated; no lesions noted. Cervix is pink and nulliparous. Scant clear to cloudy drainage present. On bimanual exam, cervix is firm. No CMT. Uterus is antevert and positioned behind a slightly distended bladder; no fullness, masses, or tenderness.  No adnexal masses or tenderness. Ovaries are nonpalpable._<br>_(Male:  Both testes are palpable, no masses or lesions, no hernia, and no uretheral discharge.)_<br>_(Rectal as appropriate:  No evidence of hemorrhoids, fissures, bleeding, or masses—Males: Prostrate is smooth, nontender, and free from nodules, is of normal size, and sphincter tone is firm)._ |
| **Musculoskeletal**<br>_Full ROM seen in all four extremities as the patient moved about the exam room._ |
| **Neurological**<br>_Speech clear. Good tone. Posture erect. Balance stable; gait normal._ |
| **Psychiatric**<br>_Alert and oriented. Dressed in clean slacks, shirt, and coat. Maintains eye contact. Speech is soft, though clear and of normal rate and cadence; answers questions appropriately._ |
| **Lab Tests**<br>_Urinalysis—point of care test done today in the office- results positive for nitrites and blood, negative for leukocytes._<br>_Urine culture collected in office—pending results, sent to lab_<br>_Wet prep collected in office—pending results, sent to lab_ |
| **Assessment** |
| · Include at least three differential diagnoses<br>· Provide rationale for each differential diagnosis<br>· Final diagnosis<br>· Pathophysiology of primary and rationale for choosing as final |
| **Plan** |
| · Medications<br>· Non-pharmacological recommendations<br>· Diagnostic tests<br>· Patient education<br>· Culture considerations<br>· Health promotion<br>· Referrals<br>· Follow up |

**## MSN_SOAP_Note_Template_2402C1.docx**

| | | |
| — | — | — |
| **Name:** | **Pt. Encounter Number:** |
| **Date:** | **Age:** | **Sex:** |
| **SUBJECTIVE** |
| **CC:**<br>_Reason given by the patient for seeking medical care “in quotes”_ |
| **HPI:**<br>_Describe the course of the patient’s illness, including when it began, character of symptoms, location where the symptoms began, aggravating or alleviating factors, pertinent positives and negatives, other related diseases, past illnesses, and surgeries or past diagnostic testing related to the present illness._ |
| **Medications:** _(List with reason for med )_ |
| **Allergies:** _(List with reaction)_<br>**Medication Intolerances:** |
| **Past Medical History:**<br>**Chronic Illnesses/Major traumas**<br>**Hospitalizations/Surgeries**<br>_“Have you ever been told that you have  diabetes, HTN, peptic ulcer disease, asthma, lung disease, heart disease, cancer, TB, thyroid problems, kidney problems, or psychiatric diagnosis?”_ |
| **Family History**<br>_Does your mother, father, or siblings have any medical or psychiatric illnesses?  Is anyone diagnosed with: lung disease, heart disease, HTN, cancer, TB, DM, or kidney disease?_ |
| **Social History**<br>_Education level, occupational history, current living situation/partner/marital status, substance use/abuse, ETOH, tobacco, and marijuana.  Safety status_ |
| **ROS Student to ask each of these questions to the patient: “Have you had any…..”** |
| **General**<br>_Weight change, fatigue, fever, chills, night sweats,  and energy level_ | **Cardiovascular**<br>_Chest pain, palpitations, PND, orthopnea, and edema_ |
| **Skin**<br>_Delayed healing, rashes, bruising, bleeding or skin discolorations, and any changes in lesions or moles_ | **Respiratory**<br>_Cough, wheezing, hemoptysis, dyspnea, pneumonia hx, and TB_ |
| **Eyes**<br>_Corrective lenses, blurring, and visual changes of any kind_ | **Gastrointestinal**<br>_Abdominal pain, N/V/D, constipation, hepatitis, hemorrhoids, eating disorders, ulcers, and black, tarry stools_ |
| **Ears**<br>_Ear pain, hearing loss, ringing in ears, and discharge_ | **Genitourinary/Gynecological**<br>_Urgency, frequency burning, change in color of urine._<br>_Contraception, sexual activity, STDs_<br>_Female: last pap, breast, mammo, menstrual complaints, vaginal discharge, pregnancy hx_<br>_Male: prostate, PSA, urinary complaints_ |
| **Nose/Mouth/Throat**<br>_Sinus problems, dysphagia, nose bleeds or discharge, dental disease, hoarseness, and throat pain_ | **Musculoskeletal**<br>_Back pain, joint swelling, stiffness or pain, fracture hx, and osteoporosis_ |
| **Breast**<br>_SBE, lumps, bumps, or changes_ | **Neurological**<br>_Syncope, seizures, transient paralysis, weakness, paresthesias, and black-out spells_ |
| **Heme/Lymph/Endo**<br>_HIV status, bruising, blood transfusion hx, night sweats, swollen glands, increase thirst, increase hunger, and cold or heat intolerance_ | **Psychiatric**<br>_Depression, anxiety, sleeping difficulties, suicidal ideation/attempts, and previous dx_ |
| **OBJECTIVE** |
| **Weight         BMI** | **Temp** | **BP** |
| **Height** | **Pulse** | **Resp** |
| **General Appearance**<br>_Healthy-appearing adult female in no acute distress. Alert and oriented; answers questions appropriately. Slightly somber affect at first and then brighter later._ |
| **Skin**<br>_Skin is brown, warm, dry, clean, and intact. No rashes or lesions noted._ |
| **HEENT**<br>_Head is normocephalic, atraumatic, and without lesions; hair evenly distributed. Eyes:  PERRLA. EOMs intact. No conjunctival or scleral injection. Ears: Canals patent. Bilateral TMs pearly gray with positive light reflex; landmarks easily visualized. Nose: Nasal mucosa pink; normal turbinates. No septal deviation. Neck: Supple. Full ROM; no cervical lymphadenopathy; no occipital nodes. No thyromegaly or nodules. Oral mucosa, pink and moist. Pharynx is nonerythematous and without exudate. Teeth are in good repair_. |
| **Cardiovascular**<br>_S1, S2 with regular rate and rhythm. No extra sounds, clicks, rubs, or murmurs. Capillary refills two seconds. Pulses 3+ throughout. No edema._ |
| **Respiratory**<br>_Symmetric chest wall. Respirations regular and easy; lungs clear to auscultation bilaterally_. |
| **Gastrointestinal**<br>_Abdomen obese; BS active in all the four quadrants. Abdomen soft, nontender. No hepatosplenomegaly_. |
| **Breast**<br>_Breast is free from masses or tenderness, no discharge, no dimpling, wrinkling, or discoloration of the skin_. |
| **Genitourinary**<br>_Bladder is nondistended; no CVA tenderness. External genitalia reveals coarse pubic hair in normal distribution; skin color is consistent with general pigmentation. No vulvar lesions noted. Well estrogenized. A small speculum was inserted; vaginal walls are pink and well rugated; no lesions noted. Cervix is pink and nulliparous. Scant clear to cloudy drainage present. On bimanual exam, cervix is firm. No CMT. Uterus is antevert and positioned behind a slightly distended bladder; no fullness, masses, or tenderness.  No adnexal masses or tenderness. Ovaries are nonpalpable._<br>_(Male:  Both testes are palpable, no masses or lesions, no hernia, and no uretheral discharge.)_<br>_(Rectal as appropriate:  No evidence of hemorrhoids, fissures, bleeding, or masses—Males: Prostrate is smooth, nontender, and free from nodules, is of normal size, and sphincter tone is firm)._ |
| **Musculoskeletal**<br>_Full ROM seen in all four extremities as the patient moved about the exam room._ |
| **Neurological**<br>_Speech clear. Good tone. Posture erect. Balance stable; gait normal._ |
| **Psychiatric**<br>_Alert and oriented. Dressed in clean slacks, shirt, and coat. Maintains eye contact. Speech is soft, though clear and of normal rate and cadence; answers questions appropriately._ |
| **Lab Tests**<br>_Urinalysis—point of care test done today in the office- results positive for nitrites and blood, negative for leukocytes._<br>_Urine culture collected in office—pending results, sent to lab_<br>_Wet prep collected in office—pending results, sent to lab_ |
| **Assessment** |
| · Include at least three differential diagnoses<br>· Provide rationale for each differential diagnosis<br>· Final diagnosis<br>· Pathophysiology of primary and rationale for choosing as final |
| **Plan** |
| · Medications<br>· Non-pharmacological recommendations<br>· Diagnostic tests<br>· Patient education<br>· Culture considerations<br>· Health promotion<br>· Referrals<br>· Follow up |

**## 674unit4assignment.docx**

**Case Study 4:** Mrs. Julie presents with mood symptoms and is at risk for suicide. Refer to assignment directions in Tab #2 for further information.

Your writing assignment should:

· follow the conventions of Standard English (correct grammar, punctuation, etc.);

· be well ordered, logical, and unified, as well as original and insightful;

· display superior content, organization, style, and mechanics; and;

· use APA formatting and citation style.

**Case Study Scenario:**

Mrs. Julie is a widowed 77-year-old retired bank teller who has been brought to the emergency department by her son and daughter as they have been worried about her mood for the past couple of months. This afternoon, when they were both over for a visit, hoping to convince their mom to go out to dinner with the family, Mrs. Julie admitted to them that she felt so terrible that she wanted to die. Her family became very concerned and decided to bring her to the hospital for assessment.

Mrs. Julie was assessed by the emergency physician, who did not feel there were any acute systemic medical illnesses and referred her to the emergency psychiatric team to evaluate her suicidal risk. During her assessment with the on-call psychiatrist, Mrs. Julie admits that she has been feeling lonely and down for about the past 3 months. Her husband of 53 years had passed away 6 months ago suddenly from a massive heart attack. Mrs. Julie thought she managed quite well initially. Even though she was sad that he was gone, she could still do what was needed at the time — making funeral arrangements and dealing with the lawyer and all the necessary paperwork. Then, about 3 months ago, it all just “hit” her. She was feeling very lonely, particularly at nighttime when she would lie in bed, staring at the ceiling and unable to fall asleep. She continued to feel worse as time passed, walking around the house aimlessly during the daytime, looking for something to do, and eventually ending up sleeping on the couch, so she would no longer have to think. She became increasingly withdrawn and stopped calling her family and friends as she did not feel like talking to anyone.

Mrs. Julie was still keeping up with her personal hygiene but stopped doing housework about a month ago. In the past 2 weeks, she has not felt much like cooking and is just eating crackers and peanut butter. In the past 2 days, she has thought that it would be easier if she could join her husband in death and be at peace.

Before the arrival of her family at her house today, she was looking at her medications and thinking it would be nice to take all of her “sleeping pills” at once. She became very scared by her thoughts. When her children arrived, she told them what she had been thinking. Currently, while she has no plans to kill herself, she is afraid those thoughts would come back when she goes home alone as she does not see any reason to live.

Mrs. Julie states that she has never felt like this before in her life. She has always been a very upbeat and energetic person. While she may have gone through some difficult periods in the past, she states that she has always managed to get through these times without help. She has never needed to see a psychiatrist for any reason. She denies ever drinking alcohol excessively and denies the use of any illicit drugs.

Medical history revealed that she had a left-side stroke about 10 years ago with full recovery. She has hypertension and hyperlipidemia; these conditions are treated and controlled. Her primary care physician recently told her she is “borderline diabetic.” She also had a significant gastrointestinal bleed about 5 years ago due to a peptic ulcer. She had a remote tonsillectomy and an appendectomy about 15 years ago. Mrs. Julie has a younger sister who went through a “nervous breakdown” after a miscarriage. Mrs. Julie thinks her sister may have been on medication for her “nerves” for a while but does not know of her specific diagnosis or the name of the medication.

Mrs. Julie’s medications included rosuvastatin 10 mg daily, metoprolol 12.5 mg twice daily, aspirin 81 mg daily, pantoprazole 40 mg daily, clopidogrel 75 mg daily, and lorazepam 1 mg every 2 hour as needed (started by her primary care physician after her husband passed away; she takes it about three times a week). Laboratory investigations ordered by the emergency physician included CBC, electrolytes, creatinine (Cr), estimated glomerular filtration rate (eGFR), aspartate aminotransferase (AST), gamma-glutamyl transferase (GGT), alanine aminotransferase (ALT), random glucose, and a urinalysis. Other than a slightly high random glucose of 13.4 mmol/L (241.2 mg/dl), all other blood test results were within normal limits.

Use the SOAP note template to complete the documentation with the information provided.

· Formulate appropriate diagnoses and design an appropriate treatment plan.

· Explain what further information you will explore to aid in forming an accurate diagnosis.

· What treatment management would you recommended for this patient?

· How would you predict Julie’s response to treatment?

· Discuss clinical judgment and interventions to enhance the client’s safety.

[**Unit 4 Assignment Grading Rubric**](https://purdueglobal.brightspace.com/d2l/common/dialogs/quickLink/quickLink.d2l?ou=398929&type=rubric&rCode=kaplan-3651864)

**## MSN_SOAP_Note_Template_2402C1.docx**

| | | |
| — | — | — |
| **Name:** | **Pt. Encounter Number:** |
| **Date:** | **Age:** | **Sex:** |
| **SUBJECTIVE** |
| **CC:**<br>_Reason given by the patient for seeking medical care “in quotes”_ |
| **HPI:**<br>_Describe the course of the patient’s illness, including when it began, character of symptoms, location where the symptoms began, aggravating or alleviating factors, pertinent positives and negatives, other related diseases, past illnesses, and surgeries or past diagnostic testing related to the present illness._ |
| **Medications:** _(List with reason for med )_ |
| **Allergies:** _(List with reaction)_<br>**Medication Intolerances:** |
| **Past Medical History:**<br>**Chronic Illnesses/Major traumas**<br>**Hospitalizations/Surgeries**<br>_“Have you ever been told that you have  diabetes, HTN, peptic ulcer disease, asthma, lung disease, heart disease, cancer, TB, thyroid problems, kidney problems, or psychiatric diagnosis?”_ |
| **Family History**<br>_Does your mother, father, or siblings have any medical or psychiatric illnesses?  Is anyone diagnosed with: lung disease, heart disease, HTN, cancer, TB, DM, or kidney disease?_ |
| **Social History**<br>_Education level, occupational history, current living situation/partner/marital status, substance use/abuse, ETOH, tobacco, and marijuana.  Safety status_ |
| **ROS Student to ask each of these questions to the patient: “Have you had any…..”** |
| **General**<br>_Weight change, fatigue, fever, chills, night sweats,  and energy level_ | **Cardiovascular**<br>_Chest pain, palpitations, PND, orthopnea, and edema_ |
| **Skin**<br>_Delayed healing, rashes, bruising, bleeding or skin discolorations, and any changes in lesions or moles_ | **Respiratory**<br>_Cough, wheezing, hemoptysis, dyspnea, pneumonia hx, and TB_ |
| **Eyes**<br>_Corrective lenses, blurring, and visual changes of any kind_ | **Gastrointestinal**<br>_Abdominal pain, N/V/D, constipation, hepatitis, hemorrhoids, eating disorders, ulcers, and black, tarry stools_ |
| **Ears**<br>_Ear pain, hearing loss, ringing in ears, and discharge_ | **Genitourinary/Gynecological**<br>_Urgency, frequency burning, change in color of urine._<br>_Contraception, sexual activity, STDs_<br>_Female: last pap, breast, mammo, menstrual complaints, vaginal discharge, pregnancy hx_<br>_Male: prostate, PSA, urinary complaints_ |
| **Nose/Mouth/Throat**<br>_Sinus problems, dysphagia, nose bleeds or discharge, dental disease, hoarseness, and throat pain_ | **Musculoskeletal**<br>_Back pain, joint swelling, stiffness or pain, fracture hx, and osteoporosis_ |
| **Breast**<br>_SBE, lumps, bumps, or changes_ | **Neurological**<br>_Syncope, seizures, transient paralysis, weakness, paresthesias, and black-out spells_ |
| **Heme/Lymph/Endo**<br>_HIV status, bruising, blood transfusion hx, night sweats, swollen glands, increase thirst, increase hunger, and cold or heat intolerance_ | **Psychiatric**<br>_Depression, anxiety, sleeping difficulties, suicidal ideation/attempts, and previous dx_ |
| **OBJECTIVE** |
| **Weight         BMI** | **Temp** | **BP** |
| **Height** | **Pulse** | **Resp** |
| **General Appearance**<br>_Healthy-appearing adult female in no acute distress. Alert and oriented; answers questions appropriately. Slightly somber affect at first and then brighter later._ |
| **Skin**<br>_Skin is brown, warm, dry, clean, and intact. No rashes or lesions noted._ |
| **HEENT**<br>_Head is normocephalic, atraumatic, and without lesions; hair evenly distributed. Eyes:  PERRLA. EOMs intact. No conjunctival or scleral injection. Ears: Canals patent. Bilateral TMs pearly gray with positive light reflex; landmarks easily visualized. Nose: Nasal mucosa pink; normal turbinates. No septal deviation. Neck: Supple. Full ROM; no cervical lymphadenopathy; no occipital nodes. No thyromegaly or nodules. Oral mucosa, pink and moist. Pharynx is nonerythematous and without exudate. Teeth are in good repair_. |
| **Cardiovascular**<br>_S1, S2 with regular rate and rhythm. No extra sounds, clicks, rubs, or murmurs. Capillary refills two seconds. Pulses 3+ throughout. No edema._ |
| **Respiratory**<br>_Symmetric chest wall. Respirations regular and easy; lungs clear to auscultation bilaterally_. |
| **Gastrointestinal**<br>_Abdomen obese; BS active in all the four quadrants. Abdomen soft, nontender. No hepatosplenomegaly_. |
| **Breast**<br>_Breast is free from masses or tenderness, no discharge, no dimpling, wrinkling, or discoloration of the skin_. |
| **Genitourinary**<br>_Bladder is nondistended; no CVA tenderness. External genitalia reveals coarse pubic hair in normal distribution; skin color is consistent with general pigmentation. No vulvar lesions noted. Well estrogenized. A small speculum was inserted; vaginal walls are pink and well rugated; no lesions noted. Cervix is pink and nulliparous. Scant clear to cloudy drainage present. On bimanual exam, cervix is firm. No CMT. Uterus is antevert and positioned behind a slightly distended bladder; no fullness, masses, or tenderness.  No adnexal masses or tenderness. Ovaries are nonpalpable._<br>_(Male:  Both testes are palpable, no masses or lesions, no hernia, and no uretheral discharge.)_<br>_(Rectal as appropriate:  No evidence of hemorrhoids, fissures, bleeding, or masses—Males: Prostrate is smooth, nontender, and free from nodules, is of normal size, and sphincter tone is firm)._ |
| **Musculoskeletal**<br>_Full ROM seen in all four extremities as the patient moved about the exam room._ |
| **Neurological**<br>_Speech clear. Good tone. Posture erect. Balance stable; gait normal._ |
| **Psychiatric**<br>_Alert and oriented. Dressed in clean slacks, shirt, and coat. Maintains eye contact. Speech is soft, though clear and of normal rate and cadence; answers questions appropriately._ |
| **Lab Tests**<br>_Urinalysis—point of care test done today in the office- results positive for nitrites and blood, negative for leukocytes._<br>_Urine culture collected in office—pending results, sent to lab_<br>_Wet prep collected in office—pending results, sent to lab_ |
| **Assessment** |
| · Include at least three differential diagnoses<br>· Provide rationale for each differential diagnosis<br>· Final diagnosis<br>· Pathophysiology of primary and rationale for choosing as final |
| **Plan** |
| · Medications<br>· Non-pharmacological recommendations<br>· Diagnostic tests<br>· Patient education<br>· Culture considerations<br>· Health promotion<br>· Referrals<br>· Follow up |

**## 674unit4assignment.docx**

**Case Study 4:** Mrs. Julie presents with mood symptoms and is at risk for suicide. Refer to assignment directions in Tab #2 for further information.

Your writing assignment should:

· follow the conventions of Standard English (correct grammar, punctuation, etc.);

· be well ordered, logical, and unified, as well as original and insightful;

· display superior content, organization, style, and mechanics; and;

· use APA formatting and citation style.

**Case Study Scenario:**

Mrs. Julie is a widowed 77-year-old retired bank teller who has been brought to the emergency department by her son and daughter as they have been worried about her mood for the past couple of months. This afternoon, when they were both over for a visit, hoping to convince their mom to go out to dinner with the family, Mrs. Julie admitted to them that she felt so terrible that she wanted to die. Her family became very concerned and decided to bring her to the hospital for assessment.

Mrs. Julie was assessed by the emergency physician, who did not feel there were any acute systemic medical illnesses and referred her to the emergency psychiatric team to evaluate her suicidal risk. During her assessment with the on-call psychiatrist, Mrs. Julie admits that she has been feeling lonely and down for about the past 3 months. Her husband of 53 years had passed away 6 months ago suddenly from a massive heart attack. Mrs. Julie thought she managed quite well initially. Even though she was sad that he was gone, she could still do what was needed at the time — making funeral arrangements and dealing with the lawyer and all the necessary paperwork. Then, about 3 months ago, it all just “hit” her. She was feeling very lonely, particularly at nighttime when she would lie in bed, staring at the ceiling and unable to fall asleep. She continued to feel worse as time passed, walking around the house aimlessly during the daytime, looking for something to do, and eventually ending up sleeping on the couch, so she would no longer have to think. She became increasingly withdrawn and stopped calling her family and friends as she did not feel like talking to anyone.

Mrs. Julie was still keeping up with her personal hygiene but stopped doing housework about a month ago. In the past 2 weeks, she has not felt much like cooking and is just eating crackers and peanut butter. In the past 2 days, she has thought that it would be easier if she could join her husband in death and be at peace.

Before the arrival of her family at her house today, she was looking at her medications and thinking it would be nice to take all of her “sleeping pills” at once. She became very scared by her thoughts. When her children arrived, she told them what she had been thinking. Currently, while she has no plans to kill herself, she is afraid those thoughts would come back when she goes home alone as she does not see any reason to live.

Mrs. Julie states that she has never felt like this before in her life. She has always been a very upbeat and energetic person. While she may have gone through some difficult periods in the past, she states that she has always managed to get through these times without help. She has never needed to see a psychiatrist for any reason. She denies ever drinking alcohol excessively and denies the use of any illicit drugs.

Medical history revealed that she had a left-side stroke about 10 years ago with full recovery. She has hypertension and hyperlipidemia; these conditions are treated and controlled. Her primary care physician recently told her she is “borderline diabetic.” She also had a significant gastrointestinal bleed about 5 years ago due to a peptic ulcer. She had a remote tonsillectomy and an appendectomy about 15 years ago. Mrs. Julie has a younger sister who went through a “nervous breakdown” after a miscarriage. Mrs. Julie thinks her sister may have been on medication for her “nerves” for a while but does not know of her specific diagnosis or the name of the medication.

Mrs. Julie’s medications included rosuvastatin 10 mg daily, metoprolol 12.5 mg twice daily, aspirin 81 mg daily, pantoprazole 40 mg daily, clopidogrel 75 mg daily, and lorazepam 1 mg every 2 hour as needed (started by her primary care physician after her husband passed away; she takes it about three times a week). Laboratory investigations ordered by the emergency physician included CBC, electrolytes, creatinine (Cr), estimated glomerular filtration rate (eGFR), aspartate aminotransferase (AST), gamma-glutamyl transferase (GGT), alanine aminotransferase (ALT), random glucose, and a urinalysis. Other than a slightly high random glucose of 13.4 mmol/L (241.2 mg/dl), all other blood test results were within normal limits.

Use the SOAP note template to complete the documentation with the information provided.

· Formulate appropriate diagnoses and design an appropriate treatment plan.

· Explain what further information you will explore to aid in forming an accurate diagnosis.

· What treatment management would you recommended for this patient?

· How would you predict Julie’s response to treatment?

· Discuss clinical judgment and interventions to enhance the client’s safety.

[**Unit 4 Assignment Grading Rubric**](https://purdueglobal.brightspace.com/d2l/common/dialogs/quickLink/quickLink.d2l?ou=398929&type=rubric&rCode=kaplan-3651864)

**## MSN_SOAP_Note_Template_2402C1.docx**

| | | |
| — | — | — |
| **Name:** | **Pt. Encounter Number:** |
| **Date:** | **Age:** | **Sex:** |
| **SUBJECTIVE** |
| **CC:**<br>_Reason given by the patient for seeking medical care “in quotes”_ |
| **HPI:**<br>_Describe the course of the patient’s illness, including when it began, character of symptoms, location where the symptoms began, aggravating or alleviating factors, pertinent positives and negatives, other related diseases, past illnesses, and surgeries or past diagnostic testing related to the present illness._ |
| **Medications:** _(List with reason for med )_ |
| **Allergies:** _(List with reaction)_<br>**Medication Intolerances:** |
| **Past Medical History:**<br>**Chronic Illnesses/Major traumas**<br>**Hospitalizations/Surgeries**<br>_“Have you ever been told that you have  diabetes, HTN, peptic ulcer disease, asthma, lung disease, heart disease, cancer, TB, thyroid problems, kidney problems, or psychiatric diagnosis?”_ |
| **Family History**<br>_Does your mother, father, or siblings have any medical or psychiatric illnesses?  Is anyone diagnosed with: lung disease, heart disease, HTN, cancer, TB, DM, or kidney disease?_ |
| **Social History**<br>_Education level, occupational history, current living situation/partner/marital status, substance use/abuse, ETOH, tobacco, and marijuana.  Safety status_ |
| **ROS Student to ask each of these questions to the patient: “Have you had any…..”** |
| **General**<br>_Weight change, fatigue, fever, chills, night sweats,  and energy level_ | **Cardiovascular**<br>_Chest pain, palpitations, PND, orthopnea, and edema_ |
| **Skin**<br>_Delayed healing, rashes, bruising, bleeding or skin discolorations, and any changes in lesions or moles_ | **Respiratory**<br>_Cough, wheezing, hemoptysis, dyspnea, pneumonia hx, and TB_ |
| **Eyes**<br>_Corrective lenses, blurring, and visual changes of any kind_ | **Gastrointestinal**<br>_Abdominal pain, N/V/D, constipation, hepatitis, hemorrhoids, eating disorders, ulcers, and black, tarry stools_ |
| **Ears**<br>_Ear pain, hearing loss, ringing in ears, and discharge_ | **Genitourinary/Gynecological**<br>_Urgency, frequency burning, change in color of urine._<br>_Contraception, sexual activity, STDs_<br>_Female: last pap, breast, mammo, menstrual complaints, vaginal discharge, pregnancy hx_<br>_Male: prostate, PSA, urinary complaints_ |
| **Nose/Mouth/Throat**<br>_Sinus problems, dysphagia, nose bleeds or discharge, dental disease, hoarseness, and throat pain_ | **Musculoskeletal**<br>_Back pain, joint swelling, stiffness or pain, fracture hx, and osteoporosis_ |
| **Breast**<br>_SBE, lumps, bumps, or changes_ | **Neurological**<br>_Syncope, seizures, transient paralysis, weakness, paresthesias, and black-out spells_ |
| **Heme/Lymph/Endo**<br>_HIV status, bruising, blood transfusion hx, night sweats, swollen glands, increase thirst, increase hunger, and cold or heat intolerance_ | **Psychiatric**<br>_Depression, anxiety, sleeping difficulties, suicidal ideation/attempts, and previous dx_ |
| **OBJECTIVE** |
| **Weight         BMI** | **Temp** | **BP** |
| **Height** | **Pulse** | **Resp** |
| **General Appearance**<br>_Healthy-appearing adult female in no acute distress. Alert and oriented; answers questions appropriately. Slightly somber affect at first and then brighter later._ |
| **Skin**<br>_Skin is brown, warm, dry, clean, and intact. No rashes or lesions noted._ |
| **HEENT**<br>_Head is normocephalic, atraumatic, and without lesions; hair evenly distributed. Eyes:  PERRLA. EOMs intact. No conjunctival or scleral injection. Ears: Canals patent. Bilateral TMs pearly gray with positive light reflex; landmarks easily visualized. Nose: Nasal mucosa pink; normal turbinates. No septal deviation. Neck: Supple. Full ROM; no cervical lymphadenopathy; no occipital nodes. No thyromegaly or nodules. Oral mucosa, pink and moist. Pharynx is nonerythematous and without exudate. Teeth are in good repair_. |
| **Cardiovascular**<br>_S1, S2 with regular rate and rhythm. No extra sounds, clicks, rubs, or murmurs. Capillary refills two seconds. Pulses 3+ throughout. No edema._ |
| **Respiratory**<br>_Symmetric chest wall. Respirations regular and easy; lungs clear to auscultation bilaterally_. |
| **Gastrointestinal**<br>_Abdomen obese; BS active in all the four quadrants. Abdomen soft, nontender. No hepatosplenomegaly_. |
| **Breast**<br>_Breast is free from masses or tenderness, no discharge, no dimpling, wrinkling, or discoloration of the skin_. |
| **Genitourinary**<br>_Bladder is nondistended; no CVA tenderness. External genitalia reveals coarse pubic hair in normal distribution; skin color is consistent with general pigmentation. No vulvar lesions noted. Well estrogenized. A small speculum was inserted; vaginal walls are pink and well rugated; no lesions noted. Cervix is pink and nulliparous. Scant clear to cloudy drainage present. On bimanual exam, cervix is firm. No CMT. Uterus is antevert and positioned behind a slightly distended bladder; no fullness, masses, or tenderness.  No adnexal masses or tenderness. Ovaries are nonpalpable._<br>_(Male:  Both testes are palpable, no masses or lesions, no hernia, and no uretheral discharge.)_<br>_(Rectal as appropriate:  No evidence of hemorrhoids, fissures, bleeding, or masses—Males: Prostrate is smooth, nontender, and free from nodules, is of normal size, and sphincter tone is firm)._ |
| **Musculoskeletal**<br>_Full ROM seen in all four extremities as the patient moved about the exam room._ |
| **Neurological**<br>_Speech clear. Good tone. Posture erect. Balance stable; gait normal._ |
| **Psychiatric**<br>_Alert and oriented. Dressed in clean slacks, shirt, and coat. Maintains eye contact. Speech is soft, though clear and of normal rate and cadence; answers questions appropriately._ |
| **Lab Tests**<br>_Urinalysis—point of care test done today in the office- results positive for nitrites and blood, negative for leukocytes._<br>_Urine culture collected in office—pending results, sent to lab_<br>_Wet prep collected in office—pending results, sent to lab_ |
| **Assessment** |
| · Include at least three differential diagnoses<br>· Provide rationale for each differential diagnosis<br>· Final diagnosis<br>· Pathophysiology of primary and rationale for choosing as final |
| **Plan** |
| · Medications<br>· Non-pharmacological recommendations<br>· Diagnostic tests<br>· Patient education<br>· Culture considerations<br>· Health promotion<br>· Referrals<br>· Follow up |