The Assignment:
Complete the Focused SOAP Note Template provided for the patient in the case study. Be sure to address the following:
- Subjective: What was the patient’s subjective complaint? What details did the patient provide regarding their history of present illness and personal and medical history? Include a list of prescription and over-the-counter drugs the patient is currently taking. Compare this list to the American Geriatrics Society Beers Criteria®, and consider alternative drugs if appropriate. Provide a review of systems.
- Objective: What observations did you note from the physical assessment? What were the lab, imaging, or functional assessments results?
- Assessment: Provide a minimum of three differential diagnoses. List them from top priority to least priority. Compare the diagnostic criteria for each, and explain what rules each differential in or out. Explain you critical thinking process that led you to the primary diagnosis you selected. Include pertinent positives and pertinent negatives for the specific patient case.
- Plan: Provide a detailed treatment plan for the patient that addresses each diagnosis, as applicable. Include documentation of diagnostic studies that will be obtained, referrals to other health-care providers, therapeutic interventions, education, disposition of the patient, caregiver support, and any planned follow-up visits. Provide a discussion of health promotion and disease prevention for the patient, taking into consideration patient factors, past medical history (PMH), and other risk factors. Finally, include a reflection statement on the case that describes insights or lessons learned.
- Provide at least three evidence-based peer-reviewed journal articles or evidenced-based guidelines, which relate to this case to support your diagnostics and differentials diagnoses. Be sure they are current (no more than 5 years old) and support the treatment plan in following current standards of care. Follow APA 7th edition formatting.
SOAP note files attached
This week your readings will focus on Endocrine, Metabolic, and Nutritional Disorders. Your assignment is to write a SOAP note based on the case study below. Review the guidelines for the SOAP note located within the module to ensure that you are addressing specific items in the note.
HPI: Ms. Donetz is a 73-year old Female who comes into your office with concerns of fatigue and dry skin. She is a retired Banker. She is AAOx4, ambulatory, and lives by herself. She does report increased fatigue no matter how much sleep she gets. She is also concerned that she
may need to come off of one of her meds because her hair is thinning. She had labs done and also was informed they would review results at this visit. Other pertinent diagnoses include Hypertension, Hyperlipidemia, and Vitamin D deficiency. She admits to not taking her vitamin D
daily as prescribed. She makes no unusual motor movements and demonstrates no tics. She denies any visual or
auditory hallucinations. She denies any suicidal thoughts or ideations. She denies any falls or
pain.
may need to come off of one of her meds because her hair is thinning. She had labs done and also was informed they would review results at this visit. Other pertinent diagnoses include Hypertension, Hyperlipidemia, and Vitamin D deficiency. She admits to not taking her vitamin D
daily as prescribed. She makes no unusual motor movements and demonstrates no tics. She denies any visual or
auditory hallucinations. She denies any suicidal thoughts or ideations. She denies any falls or
pain.
(All other Review of System and Physical Exam findings are negative other than stated.)
Vital Signs: BP 137/82, HR 89, RR 20, Temp 98.1
PMH: Hypertension, Hyperlipidemia, Vitamin D deficiency
Vital Signs: BP 137/82, HR 89, RR 20, Temp 98.1
PMH: Hypertension, Hyperlipidemia, Vitamin D deficiency
Allergies: I.V. Contrast – rash, ACE Inhibitors – cough
Medications:
Women’s One A Day-Multivitamin daily
Women’s One A Day-Multivitamin daily
Chlorthalidone 25mg daily
Fish Oil 1 tablet daily
Amlodipine 5mg p.o. daily
Losartan 100mg p.o. daily
Atorvastatin 40mg p.o. at bedtime daily
Ergocalciferol 50,000 units PO once a month
Social History: as stated in Case Study
Fish Oil 1 tablet daily
Amlodipine 5mg p.o. daily
Losartan 100mg p.o. daily
Atorvastatin 40mg p.o. at bedtime daily
Ergocalciferol 50,000 units PO once a month
Social History: as stated in Case Study
ROS: as stated in Case study
Diagnostics/Assessments done:
1. CXR- Last CXR showed no cardiopulmonary findings. WNL
2. TSH/Free T4, T3- as noted below in lab results
3. Basic Metabolic Panel and CBC as shown below
4. Vitamin D Level- as noted below in lab results
1. CXR- Last CXR showed no cardiopulmonary findings. WNL
2. TSH/Free T4, T3- as noted below in lab results
3. Basic Metabolic Panel and CBC as shown below
4. Vitamin D Level- as noted below in lab results
TEST RESULT REFERENCE
RANGE
GLUCOSE 85 65-99
SODIUM 134 L 135-146
POTASSIUM 4.2 3.5-5.3
CHLORIDE 104 98-110
CARBON
DIOXIDE
29 19-30
CALCIUM 9.0 8.6- 10.3
BUN 20 7-25
CREATININE 1.01 0.70-1.25
GLOMERULAR FILTRATION RATE (eGFR) 76 >or=60 mL/min/1.73m2
RANGE
GLUCOSE 85 65-99
SODIUM 134 L 135-146
POTASSIUM 4.2 3.5-5.3
CHLORIDE 104 98-110
CARBON
DIOXIDE
29 19-30
CALCIUM 9.0 8.6- 10.3
BUN 20 7-25
CREATININE 1.01 0.70-1.25
GLOMERULAR FILTRATION RATE (eGFR) 76 >or=60 mL/min/1.73m2
TEST RESULT REFERENCE
RANGE
TSH 23 0.4-4.0
FREE T4 0.05 0.9-2.4 mcg/dl
T3 3.0 2.0-4.4 ng/dl
Vitamin D 1,25 OH 14 36-144
RANGE
TSH 23 0.4-4.0
FREE T4 0.05 0.9-2.4 mcg/dl
T3 3.0 2.0-4.4 ng/dl
Vitamin D 1,25 OH 14 36-144
TEST RESULT REFERENCE RANGE
WBC 7.3 3.4- 10.8
RBC 4.31 4.5 – 6.1
HEMOGLOBIN 14 13-17.2
HEMATOCRIT 42% 36-50
MCV 90 80-100
MCHC 34 32-36
PLATELET 272 150-400
RBC 4.31 4.5 – 6.1
HEMOGLOBIN 14 13-17.2
HEMATOCRIT 42% 36-50
MCV 90 80-100
MCHC 34 32-36
PLATELET 272 150-400
Required Readings
- Kennedy-Malone, L., & Groenke-Duffy, E. (2023). Endocrine and metabolic disorders. In Advanced practice nursing in the care of older adults (3rd ed., pp. 437-480). F.A. Davis.
- American Diabetes Association. (2020). Glycemic targets: Standards of medical care in diabetes—2020Links to an external site.. Diabetes Care, 43(Suppl. 1), S66–S76. https://doi.org/10.2337/dc20-S006
- Munshi, M., Nathan, D. M., Schmader, K. E., Mulder, J. E., & Givens, J. (2019). Treatment of type 2 diabetes mellitus in the older patientLinks to an external site.. UpToDate. Retrieved June 8, 2020, from https://www.uptodate.com/contents/treatment-of-type-2-diabetes-mellitus-in-the-older-patient
- NRNP_6540_Week9_Assignment_Rubric
- 10 to >9.0 pts
Excellent
The response throughly and accurately describes the patient’s subjective complaint, history of present illness, current medications, allergies, medical history, and review of all systems that would inform a differential diagnosis. A thorough cross-check of medications against the Beers Criteria has been completed and appropriate alternative drugs recommended if applicable
10 to >9.0 pts
Excellent
The response thoroughly and accurately documents the patient’s physical exam for pertinent systems. Diagnostic tests and their results are thoroughly and accurately documented.
25 to >23.0 pts
Excellent
The response lists in order of priority at least three distinctly different and detailed possible conditions for a differential diagnosis of the patient in the assigned case study, and provides a thorough, accurate, and detailed justification for each of the conditions selected
0 to >27.0 pts
Excellent
The response thoroughly and accurately outlines a treatment plan for the patient that addresses each diagnosis and includes diagnostic studies neeed, referrals, therapeutic interventions, patient education and disposition, and planned follow-up visits. A thorough and accurate discussion of health promotion and disease prevention related to the case is provided. Reflections on the case demonstrate strong critical thinking and synthesis of ideas.
10 to >9.0 pts
Excellent
The response provides at least three current, evidence-based resources from the literature to support the treatment plan for the patient in the assigned case study. Each resource represents the latest in standards of care and provides strong justification for treatment decisions
- Kennedy-Malone, L., & Groenke-Duffy, E. (2023). Endocrine and metabolic disorders. In Advanced practice nursing in the care of older adults (3rd ed., pp. 437-480). F.A. Davis.
- American Diabetes Association. (2020). Glycemic targets: Standards of medical care in diabetes—2020Links to an external site.. Diabetes Care, 43(Suppl. 1), S66–S76. https://doi.org/10.2337/dc20-S006
- Munshi, M., Nathan, D. M., Schmader, K. E., Mulder, J. E., & Givens, J. (2019). Treatment of type 2 diabetes mellitus in the older patientLinks to an external site.. UpToDate. Retrieved June 8, 2020, from https://www.uptodate.com/contents/treatment-of-type-2-diabetes-mellitus-in-the-older-patient
- NRNP_6540_Week9_Assignment_Rubric
- 10 to >9.0 pts
ExcellentThe response throughly and accurately describes the patient’s subjective complaint, history of present illness, current medications, allergies, medical history, and review of all systems that would inform a differential diagnosis. A thorough cross-check of medications against the Beers Criteria has been completed and appropriate alternative drugs recommended if applicable10 to >9.0 ptsExcellentThe response thoroughly and accurately documents the patient’s physical exam for pertinent systems. Diagnostic tests and their results are thoroughly and accurately documented.25 to >23.0 ptsExcellentThe response lists in order of priority at least three distinctly different and detailed possible conditions for a differential diagnosis of the patient in the assigned case study, and provides a thorough, accurate, and detailed justification for each of the conditions selected0 to >27.0 ptsExcellentThe response thoroughly and accurately outlines a treatment plan for the patient that addresses each diagnosis and includes diagnostic studies neeed, referrals, therapeutic interventions, patient education and disposition, and planned follow-up visits. A thorough and accurate discussion of health promotion and disease prevention related to the case is provided. Reflections on the case demonstrate strong critical thinking and synthesis of ideas.10 to >9.0 ptsExcellentThe response provides at least three current, evidence-based resources from the literature to support the treatment plan for the patient in the assigned case study. Each resource represents the latest in standards of care and provides strong justification for treatment decisions