Assignment Prompt & Instructions
see attached
**files (2)**
– ## 674unit8assignmentinstructions.docx
– ## MSN_SOAP_Note_Template_2402C2.docx
**## 674unit8assignmentinstructions.docx**
**Case Study 8:** 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.
Submit your assignment to the unit Dropbox before midnight on the last day of the unit.
**Assignment Directions**
Case Study Scenario:
You are a PMHNP working on an inpatient geriatric psychiatry unit. Your new admission today is Mr. Dennis., a 72-year-old single male resident from an assisted living facility. He was brought to the emergency department with “physical aggression and bizarre behaviors.” Mr. Dennis. has no known premorbid psychiatric history. Two years ago, he was diagnosed with a mild neurocognitive disorder, major depressive disorder, and generalized anxiety disorder. He is unmarried with no children and lived independently in an apartment until 6 months ago. His recent symptoms of depression and anxiety were attributed to his transition to retirement from teaching at age 65. He had worked as a high school mathematics teacher for 3 decades and was highly active in his local church. Following his retirement, his cognitive decline progressed, and he subsequently began to experience progressive Parkinsonian symptoms, including mild intention tremor, cogwheeling rigidity, and bradykinesia. Recurrent falls and functional decline led to his eventual admission to the assisted living facility, as he required assistance with bathing, dressing, cooking, and medication management. He was seen by the facility’s physician and referred to a neurology service to evaluate his Parkinsonian symptoms.
Assisted living staff members report that he appears intermittently confused and disoriented and endorses visual hallucinations of insects and children in his room. He was initially insightful regarding these perceptual disturbances and easily reassured by staff. He was often seen in his room contentedly interacting with hallucinatory figures. Over the past month, he has expressed concerns that someone in the facility wants to harm him and that “nothing is real.” With no apparent trigger, he has repeatedly become increasingly volatile and physically aggressive toward co-residents. At other times he appears entirely lucid and engages appropriately with staff and co-residents. His sleep is erratic, and he has been observed thrashing his legs in his bed on nightly rounds. He is eating well, has normal bowel and bladder function, and denies any pain. There are no intercurrent medical illnesses and no infectious symptoms noted. There is no known family psychiatric history.
Past medical history is significant for dyslipidemia treated with a statin. He otherwise does not have any vascular risk factors. There is no history of traumatic brain injury. He is a non-smoker and a nondrinker with no illicit drug use. His current medications include atorvastatin 40 mg po daily and risperidone 0.5 mg po qhs, which the facility’s physician recently started for psychosis. There are no known drug allergies.
On physical examination in the emergency department, Mr. Dennis. presented as afebrile with normal vital signs, and worsening Parkinsonian symptoms were noted. The emergency physician noted that he appeared “perplexed” and endorsed visual hallucinations of small animals running around the ward. Mental status examination revealed a casually dressed and mildly disheveled older male who seemed his stated age. He presented as confused but was able to tolerate a short interview. The speech was of normal rate, rhythm, and volume. The mood was described as “not bad,” and the affect was slightly blunted. Thoughts were disorganized, and perceptions revealed prominent visual hallucinations. He denied suicidality and homicidal. Insight and judgment were impaired due to confusion. Brief cognitive testing showed a MoCA of 21 out of 30, with deficits in visuospatial and executive function. Laboratory investigations showed dehydration and mild leukocytosis, with urine culture positive for E. coli bacteriuria. He was started on intravenous fluids and an antibiotic.
Use the SOAP note template to complete the documentation with the information provided.
· Formulate appropriate diagnoses and design a treatment plan.
· Explain what further information you will explore to aid in accurate diagnosis.
· What treatment management is recommended for this patient, including pharmacological management?
· Discuss any need for referral.
· Discuss evidence-based treatment approaches for a client with neurocognitive disorder.
**Assignment Requirements**
Before finalizing your work, you should:
· be sure to read the assignment description carefully (as displayed above);
· consult the
[**Grading Rubric**](https://purdueglobal.brightspace.com/d2l/common/dialogs/quickLink/quickLink.d2l?ou=398929&type=rubric&rCode=kaplan-3651866) to make sure you have included everything necessary; and
· utilize spelling and grammar check to minimize errors.
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 7th edition format.
**## MSN_SOAP_Note_Template_2402C2.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_2402C2.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 |
**## 674unit8assignmentinstructions.docx**
**Case Study 8:** 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.
Submit your assignment to the unit Dropbox before midnight on the last day of the unit.
**Assignment Directions**
Case Study Scenario:
You are a PMHNP working on an inpatient geriatric psychiatry unit. Your new admission today is Mr. Dennis., a 72-year-old single male resident from an assisted living facility. He was brought to the emergency department with “physical aggression and bizarre behaviors.” Mr. Dennis. has no known premorbid psychiatric history. Two years ago, he was diagnosed with a mild neurocognitive disorder, major depressive disorder, and generalized anxiety disorder. He is unmarried with no children and lived independently in an apartment until 6 months ago. His recent symptoms of depression and anxiety were attributed to his transition to retirement from teaching at age 65. He had worked as a high school mathematics teacher for 3 decades and was highly active in his local church. Following his retirement, his cognitive decline progressed, and he subsequently began to experience progressive Parkinsonian symptoms, including mild intention tremor, cogwheeling rigidity, and bradykinesia. Recurrent falls and functional decline led to his eventual admission to the assisted living facility, as he required assistance with bathing, dressing, cooking, and medication management. He was seen by the facility’s physician and referred to a neurology service to evaluate his Parkinsonian symptoms.
Assisted living staff members report that he appears intermittently confused and disoriented and endorses visual hallucinations of insects and children in his room. He was initially insightful regarding these perceptual disturbances and easily reassured by staff. He was often seen in his room contentedly interacting with hallucinatory figures. Over the past month, he has expressed concerns that someone in the facility wants to harm him and that “nothing is real.” With no apparent trigger, he has repeatedly become increasingly volatile and physically aggressive toward co-residents. At other times he appears entirely lucid and engages appropriately with staff and co-residents. His sleep is erratic, and he has been observed thrashing his legs in his bed on nightly rounds. He is eating well, has normal bowel and bladder function, and denies any pain. There are no intercurrent medical illnesses and no infectious symptoms noted. There is no known family psychiatric history.
Past medical history is significant for dyslipidemia treated with a statin. He otherwise does not have any vascular risk factors. There is no history of traumatic brain injury. He is a non-smoker and a nondrinker with no illicit drug use. His current medications include atorvastatin 40 mg po daily and risperidone 0.5 mg po qhs, which the facility’s physician recently started for psychosis. There are no known drug allergies.
On physical examination in the emergency department, Mr. Dennis. presented as afebrile with normal vital signs, and worsening Parkinsonian symptoms were noted. The emergency physician noted that he appeared “perplexed” and endorsed visual hallucinations of small animals running around the ward. Mental status examination revealed a casually dressed and mildly disheveled older male who seemed his stated age. He presented as confused but was able to tolerate a short interview. The speech was of normal rate, rhythm, and volume. The mood was described as “not bad,” and the affect was slightly blunted. Thoughts were disorganized, and perceptions revealed prominent visual hallucinations. He denied suicidality and homicidal. Insight and judgment were impaired due to confusion. Brief cognitive testing showed a MoCA of 21 out of 30, with deficits in visuospatial and executive function. Laboratory investigations showed dehydration and mild leukocytosis, with urine culture positive for E. coli bacteriuria. He was started on intravenous fluids and an antibiotic.
Use the SOAP note template to complete the documentation with the information provided.
· Formulate appropriate diagnoses and design a treatment plan.
· Explain what further information you will explore to aid in accurate diagnosis.
· What treatment management is recommended for this patient, including pharmacological management?
· Discuss any need for referral.
· Discuss evidence-based treatment approaches for a client with neurocognitive disorder.
**Assignment Requirements**
Before finalizing your work, you should:
· be sure to read the assignment description carefully (as displayed above);
· consult the
[**Grading Rubric**](https://purdueglobal.brightspace.com/d2l/common/dialogs/quickLink/quickLink.d2l?ou=398929&type=rubric&rCode=kaplan-3651866) to make sure you have included everything necessary; and
· utilize spelling and grammar check to minimize errors.
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 7th edition format.
**## MSN_SOAP_Note_Template_2402C2.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 |
**## 674unit8assignmentinstructions.docx**
**Case Study 8:** 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.
Submit your assignment to the unit Dropbox before midnight on the last day of the unit.
**Assignment Directions**
Case Study Scenario:
You are a PMHNP working on an inpatient geriatric psychiatry unit. Your new admission today is Mr. Dennis., a 72-year-old single male resident from an assisted living facility. He was brought to the emergency department with “physical aggression and bizarre behaviors.” Mr. Dennis. has no known premorbid psychiatric history. Two years ago, he was diagnosed with a mild neurocognitive disorder, major depressive disorder, and generalized anxiety disorder. He is unmarried with no children and lived independently in an apartment until 6 months ago. His recent symptoms of depression and anxiety were attributed to his transition to retirement from teaching at age 65. He had worked as a high school mathematics teacher for 3 decades and was highly active in his local church. Following his retirement, his cognitive decline progressed, and he subsequently began to experience progressive Parkinsonian symptoms, including mild intention tremor, cogwheeling rigidity, and bradykinesia. Recurrent falls and functional decline led to his eventual admission to the assisted living facility, as he required assistance with bathing, dressing, cooking, and medication management. He was seen by the facility’s physician and referred to a neurology service to evaluate his Parkinsonian symptoms.
Assisted living staff members report that he appears intermittently confused and disoriented and endorses visual hallucinations of insects and children in his room. He was initially insightful regarding these perceptual disturbances and easily reassured by staff. He was often seen in his room contentedly interacting with hallucinatory figures. Over the past month, he has expressed concerns that someone in the facility wants to harm him and that “nothing is real.” With no apparent trigger, he has repeatedly become increasingly volatile and physically aggressive toward co-residents. At other times he appears entirely lucid and engages appropriately with staff and co-residents. His sleep is erratic, and he has been observed thrashing his legs in his bed on nightly rounds. He is eating well, has normal bowel and bladder function, and denies any pain. There are no intercurrent medical illnesses and no infectious symptoms noted. There is no known family psychiatric history.
Past medical history is significant for dyslipidemia treated with a statin. He otherwise does not have any vascular risk factors. There is no history of traumatic brain injury. He is a non-smoker and a nondrinker with no illicit drug use. His current medications include atorvastatin 40 mg po daily and risperidone 0.5 mg po qhs, which the facility’s physician recently started for psychosis. There are no known drug allergies.
On physical examination in the emergency department, Mr. Dennis. presented as afebrile with normal vital signs, and worsening Parkinsonian symptoms were noted. The emergency physician noted that he appeared “perplexed” and endorsed visual hallucinations of small animals running around the ward. Mental status examination revealed a casually dressed and mildly disheveled older male who seemed his stated age. He presented as confused but was able to tolerate a short interview. The speech was of normal rate, rhythm, and volume. The mood was described as “not bad,” and the affect was slightly blunted. Thoughts were disorganized, and perceptions revealed prominent visual hallucinations. He denied suicidality and homicidal. Insight and judgment were impaired due to confusion. Brief cognitive testing showed a MoCA of 21 out of 30, with deficits in visuospatial and executive function. Laboratory investigations showed dehydration and mild leukocytosis, with urine culture positive for E. coli bacteriuria. He was started on intravenous fluids and an antibiotic.
Use the SOAP note template to complete the documentation with the information provided.
· Formulate appropriate diagnoses and design a treatment plan.
· Explain what further information you will explore to aid in accurate diagnosis.
· What treatment management is recommended for this patient, including pharmacological management?
· Discuss any need for referral.
· Discuss evidence-based treatment approaches for a client with neurocognitive disorder.
**Assignment Requirements**
Before finalizing your work, you should:
· be sure to read the assignment description carefully (as displayed above);
· consult the
[**Grading Rubric**](https://purdueglobal.brightspace.com/d2l/common/dialogs/quickLink/quickLink.d2l?ou=398929&type=rubric&rCode=kaplan-3651866) to make sure you have included everything necessary; and
· utilize spelling and grammar check to minimize errors.
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 7th edition format.
**## MSN_SOAP_Note_Template_2402C2.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 |