Primary, secondary and differential diagnoses for patient case study – NR601 SOAP note

Primary, secondary and differential diagnoses for patient case study – NR601 SOAP note

Mrs G, a 55 year old Hispanic female, presents to the office for her annual exam. She reports that lately she has been very fatigued and just does not seem to have any energy. This has been occurring for 3 months. She is also gaining weight since menopause last year.  She joined a gym and forces herself to go twice a week, where she walks on the treadmill at least 30 minutes but she has not lost any weight, in fact she has gained 3 pounds. She doesn’t understand what she is doing wrong. She states that exercise seems to make her even more hungry and thirsty, which is not helping her weight loss. She wants get a complete physical and to discuss why she is so tired and get some weight loss advice. She also states she thinks her bladder has fallen because she has to go to the bathroom more often, recently she is waking up twice a night to urinate and seems to be urinating more frequently during the day. This has been occurring for about 3 months too. This is irritating to her, but she is able to fall immediately back to sleep.

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Current medications: Tylenol 500 mg  2 tabs daily for knee pain. Daily multivitamin

PMH: Has left knee arthritis. Had chick pox and mumps as a child. Vaccinations up to date.

GYN hx:  G2 P1. 1 SAB,  1 living child, full term,  wt 9lbs 2 oz.   LMP 15months ago. No history of abnormal Pap smear.

FH: parents alive, well, child alive, well. No siblings. Mother has HTN and father has high cholesterol.

SH:  works from home part time as a planning coordinator. Married. No tobacco history, 1-2 glasses wine on weekends. No illicit drug use

Allergies: NKDA, allergic to cats and pollen. No latex allergy

Vital signs: BP 129/80; pulse 76, regular; respiration 16, regular

Height 5’2.5”, weight 185 pounds

General: obese female in no acute distress. Alert, oriented and cooperative.

Skin: warm dry and intact. No lesions noted

HEENT: head normocephalic. Hair thick and distribution throughout scalp. Eyes without exudate, sclera white.  Wears contacts. Tympanic membranes gray and intact with light reflex noted. Pinna and tragus nontender.  Nares patent without exudate. Oropharynx moist without erythema. Teeth in good repair, no cavities noted. Neck supple. Anterior cervical lymph nontender to palpation.  No lymphadenopathy. Thyroid midline, small and firm without palpable masses. Primary, secondary and differential diagnoses for patient case study – NR601 SOAP note .

CV: S1 and S2 RRR without murmurs or rubs

Lungs: Clear to auscultation bilaterally, respirations unlabored.

Abdomen– soft, round, nontender with positive bowel sounds present; no organomegaly; no abdominal bruits. No CVAT.

Labwork:

CBC: WBC 6,000/mm3  Hgb  12.5 gm/dl  Hct 41%  RBC 4.6 million MCV 88 fl  MCHC 34 g/dl  RDW  13.8%

UA: pH 5, SpGr 1.013, Leukocyte esterase negative, nitrites negative, 1+ glucose; small protein; negative for ketones

CMP:

Sodium 139

Potassium 4.3

Chloride 100

CO2 29

Glucose 126

BUN 12

Creatinine 0.7

GFR est non-AA  94 mL/min/1.73

GFR est AA         101 mL/min/1.73

Calcium 9.5

Total protein 7.6

Bilirubin, total 0.6

Alkaline phosphatase  72

AST 25

ALT 29

Anion gap 8.10

Bun/Creat 17.7

Hemoglobin A1C: 6.9 %

TSH: 2.35, Free T 4 0.8 ng/dL

Cholesterol: TC 230 mg/dl, LDL 144 mg/dl; VLDL 36 mg/dl; HDL 38mg/dl, Triglycerides 232

EKG: normal sinus rhythm

Use the categories below to create section headings for your paper. Review the APA Manual for paper format instructions. Primary, secondary and differential diagnoses for patient case study – NR601 SOAP note .

Introduction: briefly discuss the purpose of this paper.

Assessment: review the provided case study information.

Identify the primary, secondary and differential diagnoses for the patient. Use the 601 SOAP note format as a guide to develop your diagnoses.

Each diagnosis will include the following information:

  1. ICD 10 code.
  2. A brief pathophysiology statement which his no longer that 2 sentences, paraphrased and includes common signs and symptoms of the diagnosis.
  3. The patient’s pertinent positive and negative findings, including a brief 1-2 sentence statement which links the subjective and objective findings (including lab data and interpretation).
  4. A rationale statement which summarizes why the diagnosis was chosen.
  5. Do not include quotes, paraphrase all scholarly information and provide an intext citation to your scholarly reference. Use the Reference Guidelines document for information on scholarly references. Primary, secondary and differential diagnoses for patient case study – NR601 SOAP note .

Plan (there are five (5) sections to the management plan)

  1. List all labs and diagnostic test you would like to order. Each test includes a rationale statement following the listed lab which includes the diagnosis for the test, the purpose of the test and how the test results will contribute to your management plan. Each rationale statement is cited.
  2. Medications: Each medication is listed in prescription format. Each prescribed and OTC medication is linked to a specific diagnosis and includes a paraphrased EBP rationale for prescribing.
  3. Education: section includes personalized detailed education on all five (5) subcategories: diagnosis, each medication purpose and side effects, diet, personalized appropriate exercise recommendations and warning sign for diagnosis and medications if applicable. All education steps are linked to a diagnosis, paraphrased, and include a paraphrased EBP rationale. Review the NR601 SOAP note guideline for more detailed information. Primary, secondary and differential diagnoses for patient case study – NR601 SOAP note .
  4. Referrals: any recommended referrals are appropriate to the patient diagnosis and current condition, is linked to a specific diagnosis and includes a paraphrased EBP rationale with in text citation.
  5. Follow up: Follow up includes a specific time, not a time range, to return to PCP office for next scheduled appointment. Includes EBP rationale with in text citation. Primary, secondary and differential diagnoses for patient case study – NR601 SOAP note .

Medication costs: in this section students will research the costs of all prescribed and OTC monthly medications. Students may use Good Rx, Epocrates or another resource (can use local pharmacy websites) which provides medication costs. Students will list each medication, the monthly cost of the medication and the reference source. Students will calculate the monthly cost of the case study patient’s prescribed and OTC medications and provide the total costs of the month’s medications. Reflect on the monthly cost of the medications prescribed. Discuss if prescriptions were adjusted due to cost. Discuss if will you use medication pricing resources in future practice.

SOAP note: A focused SOAP note, written on a separate page, follows the assignment. The SOAP note is written following the provided SOAP note format.

  • The subjective section is organized to follow the SOAP note format. The ROS is focused, only pertinent body systems are included. Only provided information is included in the ROS. No additional data is added.
  • The objective section is maintained as written, no additional information is added.
  • The assessment section includes only the diagnoses and ICD 10 codes. Diagnosed are labeled as primary, secondary or differential diagnoses. Rationale is not included in the SOAP note.
  • The plan includes 5 sections. Rationale is not included in the SOAP note. Primary, secondary and differential diagnoses for patient case study – NR601 SOAP note .

The Primary, secondary and differential diagnoses for patient case study – NR601 SOAP note  assignment will be submitted through TurnItIn. Due to the common language in a large group assignment it is possible that similarity scores can exceed 25%. It is the student’s responsibility to review the TII paper and assure that sections of original work contain low similarity. If there are concerns please contact your instructor.

Category Points % Description
Assessment 50 25 Each diagnosis, primary, secondary and differential includes the ICD10 codes in parentheses next to each diagnosis. A one to two sentence paraphrased pathophysiology statement explains the diagnosis. Include pertinent positive and negative findings to support your diagnoses from the history and physical exam which links this diagnosis to your patient. Each diagnoses must include an intext citation to a scholarly reference. Diagnoses are consistent with the guideline recommendations or scholarly reference.
Evidence-Based Practice (EBP) 50 25 National guidelines, including the American Diabetes Association Standards and Medical Care in Diabetes-2017, are used as rationale to support the diagnosis and develop the management plan. Every diagnoses must include an intext citation to a scholarly reference. Each action step or order within all plan sections includes an intext citation to an appropriate reference as listed in the Reference Guidelines document.
Plan: diagnostics 10 5 Each test listed in this section includes a rationale statement which includes the diagnosis for the test, the purpose of the test and how the test results will contribute to your management plan. Each rationale statement is cited.
Plan: medications 10 5 Each prescribed and OTC medication is linked to a diagnosis, and includes a paraphrased EBP rationale and in text citation. Diagnosis is clearly stated in the rationale statement.
Plan: education 10 5 All education steps are linked to a diagnosis, paraphrased, and include an EBP rationale. Section includes personalized and detailed education on all diagnoses, medications, diet, exercise and warning signs.
Plan: Referrals 10 5 All recommended referrals are appropriate for the patient diagnosis and condition, is linked to a specific diagnosis and includes a paraphrased EBP rationale for ordering
Plan: Follow up 10 5 Follow up includes a specific time frame to return to PCP office for next scheduled appointment.
Medication costs 10 5 All prescribed medications costs, prescribed and OTC, are calculated to evaluate the total monthly medication cost for the patient. A reflection statement is included. Primary, secondary and differential diagnoses for patient case study – NR601 SOAP note
SOAP note 20 10 A SOAP note, written on a separate page, follows the assignment. The SOAP note is located prior to the Reference section. The SOAP note is written following the provided SOAP note format. Rationales are not included, this SOAP note is an example of a patient chart entry.
Grammar, Syntax, APA 10 5 APA format, grammar, spelling, and/or punctuation are accurate, or with zero to one errors. All referenced information is cited, “according to” is not used.
Organization 10 5 Paper is developed in a logical, meaningful, and understandable sequence using categories in instructions as section headings. The paper does not exceed 20 pages. Primary, secondary and differential diagnoses for patient case study – NR601 SOAP note

Each diagnosis and action step in the plan lists the step followed by the rationale. Rationale length does not exceed template directions.

Total  200 100 A quality assignment will meet or exceed all of the above requirements.

 

Grading Rubric

Criterion Exceptional

Outstanding or highest level of performance

Exceeds

Very good or high level of performance

Meets

Satisfactory level of performance

Needs Improvement

Poor or failing level of performance

Developing

Unsatisfactory level of performance

Content

Possible Points =  180

 

 

 

 

   

 

 
Assessment 50 Points 44 Points  41 Points 20 Points 0 Points
All three diagnostic categories are present.

 

Each diagnosis, primary, secondary and differential, includes the ICD10 codes in parentheses next to each diagnosis. Diagnosis is consistent with the guideline recommendations or scholarly reference.

 

Each diagnosis includes a one to two sentence paraphrased pathophysiology statement explains the diagnosis and a rationale statement.  The rationale statement includes pertinent positive and negative subjective and objective findings from the history and physical exam which links this diagnosis to your patient. Pertinent lab results are interpreted within the rationale statement.

All three diagnostic categories are present.

 

Each diagnosis, primary, secondary and differential includes the ICD10 codes in parentheses next to each diagnosis. Diagnosis is consistent with the guideline recommendations or scholarly reference.

 

Each diagnosis includes a one to two sentence paraphrased pathophysiology statement explains the diagnosis and a rationale statement.

The rationale statement includes pertinent positive and negative subjective and objective findings from the history and physical exam which links this diagnosis to your patient.

Pertinent lab or diagnostic results are not interpreted within the rationale statement.

 

All three diagnostic categories are present.

 

Each diagnosis, primary, secondary and differential includes the ICD10 codes in parentheses next to each diagnosis. Diagnosis is consistent with the guideline recommendations or scholarly reference.

 

The pathophysiology statement is not present or not paraphrased,

The rationale statement includes pertinent positive and negative subjective and objective findings from the history and physical exam which links this diagnosis to your patient.

Pertinent lab or diagnostic results are not interpreted within the rationale statement.

All three diagnostic categories are not developed: a primary, secondary or differential diagnosis category is not included. Primary, secondary and differential diagnoses for patient case study – NR601 SOAP note

 

Diagnosis is not consistent with the guideline recommendations or scholarly reference.

Diagnoses are not present.
Evidence-Based Practice 50 Points 44 Points 41 Points 20 Points 0 Points
National guidelines, including the American Diabetes Association Standards and Medical Care in Diabetes-2017, are used to support the primary diagnosis and develop the plan.

 

Every diagnosis rationale must include an intext citation to a scholarly reference. Each action step or order within all plan sections includes an intext citation to an appropriate reference as listed in the Reference Guidelines document. All cited information is paraphrased, no quotes included. Reference interpretation is accurate.

Diagnoses plan are consistent with the guideline recommendations.

National guidelines, including the American Diabetes Association Standards and Medical Care in Diabetes-2017, are used to support the primary diagnosis and develop the plan.

 

Every diagnosis rationale must include an intext citation to a scholarly reference.

 

One or two steps or orders within all plan sections may be missing an intext citation to an appropriate reference as listed in the Reference Guidelines document. All cited information is paraphrased, no quotes included.

Diagnoses plan are consistent with the guideline recommendations.

National guidelines, including the American Diabetes Association Standards and Medical Care in Diabetes-2017, are used to support the primary diagnosis and develop the plan.

 

Every diagnosis rationale does not include an intext citation to an appropriate reference as listed in the Reference Guidelines document.

 

One or two steps or orders within all plan sections may be missing an intext citation to an appropriate reference as listed in the Reference Guidelines document. All cited information is paraphrased, no quotes included.

Diagnoses plan are consistent with the guideline recommendations.

The American Diabetes Association Standards and Medical Care in Diabetes-2017 is not used to support the primary diagnosis.

 

Every diagnosis rationale does not include an intext citation to an appropriate reference as listed in the Reference Guidelines document. Reference interpretation is not accurate, diagnosis or plan is not consistent with the guideline recommendations.

 

Two steps or orders within any plan section are be missing an intext citation to an appropriate reference as listed in the Reference Guidelines document.

Scholarly information includes quotations.

Diagnoses and/or plan are not consistent with the guideline recommendations.

National guidelines, including the American Diabetes Association Standards and Medical Care in Diabetes-2017 are not used as references.

 

  10 Points 9 Points 8 Points 4 Points 0 Points
Plan: Diagnostics All ordered diagnostics tests are linked to a diagnosis and include a paraphrased EBP rationale. Each diagnosis is included in the plan.

Plans are consistent with the guideline recommendations or scholarly reference.

All ordered diagnostics tests include an EBP rationale.

Plans are consistent with the guideline recommendations or scholarly reference.

 

A diagnosis is not included within the rationale statement. Primary, secondary and differential diagnoses for patient case study – NR601 SOAP note

 

All ordered diagnostics tests are linked to a diagnosis listed in the assessment section.

Plans are consistent with the guideline recommendations or scholarly reference.

 

EBP rationale within text citation is missing;

OR

Rationale is a quotation.

Diagnostic tests include an intext citation to a non-scholarly internet or application source.

Ordered diagnostics tests are not linked to a diagnosis listed in the assessment section

Plans are not consistent with the guideline recommendations.

 

Diagnostic tests are not included

OR

Diagnostic tests do not include an intext citation.

        10 Points 9 Points 8 Points 4 Points 0 Points
Plan: Medications Each prescribed and OTC medication is linked to a diagnosis, and include a paraphrased rationale EBP rationale and in text citation. Diagnosis is clearly stated in the rationale statement.

Plans are consistent with the guideline recommendations or scholarly reference.

All prescribed and OTC medication include a paraphrased EBP rationale and in text citation. The diagnosis is not clearly listed within the rationale statement.

Plans are consistent with the guideline recommendations or scholarly reference.

Each prescribed and OTC medication is linked to a specific diagnosis. The diagnosis is clearly listed within the rationale statement. An EBP rationale is not included

OR

Rationale is a quotation.

Plans are consistent with the guideline recommendations or scholarly reference.

Prescribed medications are listed but  OTC medications are not present

Not every medication is linked to a diagnosis, and include a paraphrased rationale EBP rationale and in text citation.

Plans are not consistent with the guideline recommendation or scholarly references.

Prescribed and OTC medications are not included in the case study.
  10 Points 9 Points 8 Points 4 Points 0 Points
Plan: Education All education steps linked to a diagnosis, paraphrased, and include an EBP rationale. Section includes personalized detailed education on diagnosis, medications, diet, exercise and warning signs. Personalized diet and exercise recommendations are included.

Plans are consistent with the guideline recommendations or scholarly reference.

All education steps are linked to a diagnosis, paraphrased and include an EBP rationale. One or 2 educational areas are not detailed or personalized to the patient.

Plans are consistent with the guideline recommendations or scholarly reference.

All education steps are linked to a diagnosis and includes an EBP rationale.

OR

EBP rationale

is a quotation.

OR

Three (3) or more education areas do not include personalized detailed information or scholarly reference.

Any education step is not linked to a diagnosis, not paraphrased or an EBP rational is not provided.

Plans are not consistent with the guideline recommendations or scholarly reference.

 

Education section is not present.
  10 Points 9 Points 8 Points 4 Points 0 Points
Plan: Referral All recommended referrals are appropriate for the patient diagnosis, each referral is linked to a specific diagnosis and includes a paraphrased EBP rationale.

Plans are consistent with the guideline recommendations or scholarly reference.

Some recommended referrals are appropriate for the patient diagnosis and condition, each referral is linked to a specific diagnosis and includes a paraphrased EBP rationale for ordering.

Plans are consistent with the guideline recommendations or scholarly reference. Primary, secondary and differential diagnoses for patient case study – NR601 SOAP note

All recommended referrals are appropriate for the patient diagnosis and condition, includes a paraphrased EBP rationale but  specific diagnosis is not stated for every referral.

OR

EBP rationale

is a quotation.

Plans are consistent with the guideline recommendations or scholarly reference.

Some recommended referrals are appropriate for the patient diagnosis and condition

Does not include a paraphrased EBP rationale for referral.

 

Plans are not consistent with the guideline recommendations.

 

Referral section is not present.
  10 Points 9 Points 8 Points 4 Points 0 Points
Plan: Follow Up Follow up includes a specific time/date to return to PCP office. Includes EBP rationale with in text citation.  Only follow up information is listed in this section. Plans are EBP and consistent with the guideline recommendations. Follow up is included in the plan but a specific time/date is not included (a range is included). Includes EBP rationale with in text citation. Only follow up information is listed in this section.

Plans are EBP and consistent with the guideline recommendations.

Follow up is included in the plan but a specific time is not included. Only follow up information is listed in this section.

Plans are consistent with the guideline recommendations.

Follow up is included in the plan, recommended follow up visit time frame is not EBP. Additional information, such as future testing, education or referrals are listed.

Plans are not consistent with the guideline recommendations.

 

Follow up section not present.
  20 Points 18 Points 16 Points 8 Points 0 Points
SOAP note SOAP note included at end of assignment   before reference page.

SOAP note includes all elements and is formatted exactly as described in the SOAP note guidelines document. Rationales are not included. Only provided information is included in the SOAP note.

SOAP note included at end of assignment   before reference page.

 

SOAP note includes all elements as listed in the SOAP note but not exactly as formatted in guidelines document.

Rationales are not included.

Only provided information is included in the SOAP note.

SOAP note included at end of assignment before the reference page.

 

SOAP note is formatted exactly as listed in the SOAP note guidelines document but is missing provided subjective or objective information.  Subjective or objective information is not consistent with the case study.

 

SOAP note included, but not located at end of assignment before the reference page.

OR

SOAP note is not formatted exactly as shown in the SOAP note guidelines document and missing provided subjective or objective information.

Rationales are included. Subjective or objective information is not consistent with the case study. Additional information is included that was not provided in the case study.

 

SOAP note not included in assignment.
  10 Points 9 Points 8 Points 4 Points 0 Points
Medication costs Monthly medication costs are calculated and a total cost for the month’s medication is included.

All medications including OTCs are included.

Medication cost citation is included.  Summary/reflection statement is included.

Monthly medication costs are calculated and a total cost for the month’s medications is included.

All medications including OTCs are included.

Medication cost reference is not included. Summary/reflection statement is included.

Monthly medication costs are calculated. A total cost for the month is included.

All medications including OTCs are included.

Summary/reflection statement is not included.

Monthly medication costs are calculated.

Summary statement/reflection is included.

 

OTCs are not included in monthly medication calculations.

 

Medication costs not calculated.
Content Subtotal _____of  180 points
Format

Possible Points =   20

         
Grammar, Syntax, APA

 

 

 10 Points 9 Points 8 Points 4 Points 0 Points
APA format, grammar, spelling, and/or punctuation are accurate, or with zero to one errors. All referenced information is cited at the end of the phrase or sentence, “according to” or the reference name is not used within the rationale statement. Two to four errors in APA format, grammar, spelling, and syntax noted. All referenced information is cited at the end of the phrase or sentence, “according to” or the reference name is not used within the rationale statement. Five to seven errors in APA format, grammar, spelling, and syntax noted.” According to” is used as part of rationale. Eight to nine errors in APA format, grammar, spelling, and syntax noted. Post contains ten or greater errors in APA format, grammar, spelling, and/or punctuation.
Organization 10 Points 9 Points 8 Points 4 Points 0 Points
Paper is developed in a logical, meaningful, and understandable sequence using categories in instructions as section headings.

Each diagnosis and action step in the plan lists the step followed by the rationale. Rationale length does not exceed template directions.

 

SOAP note presents case study findings in a logical, meaningful, and understandable sequence following provided format. The paper does not exceed 20 pages.

 

Assignment contains all elements but may not be written following provided format. Rationale length does not exceed template directions.

 

 

SOAP note presents case study findings in a logical, meaningful, and understandable sequence following provided format.

The paper does not exceed 20 pages.

 

Paper does not contain all components and/or may be missing data.

OR

SOAP note is not written in SOAP note format as outlined in the NR 601 SOAP note format document. Rationale length does not exceed template directions. Primary, secondary and differential diagnoses for patient case study – NR601 SOAP note

 

The paper does not exceed 20 pages.

 

Paper is missing three or more required sections or

Diagnoses or

plans are sometimes unclear to follow and may not always be relevant to topic. Rationale length exceeds template directions.

 

The paper exceeds 20 pages.

 

Paper is not relevant to case study patient

OR

SOAP note is not relevant to case study.

Format Subtotal _____of  20 points
Total Points                                                               _____of  200 points

 Primary, secondary and differential diagnoses for patient case study – NR601 SOAP note

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