NRP 556 University of Toledo Evelyn Johnson Case Study Read Evelyn Johnson case study. Write a 700-word focused SOAP note addressing the patient’s complai

NRP 556 University of Toledo Evelyn Johnson Case Study Read Evelyn Johnson case study.

Write a 700-word focused SOAP note addressing the patient’s complaints.

Utilize the Case Study Assignment Instructions, the Sample SOAP Note, and the Episodic SOAP Note Template as a guide.

Locate a minimum of five peer-reviewed sources using the University Library that address evidence-based approaches supporting your decisions in the plan. Sources must not be more than five years old. If you’re unable to locate recent evidence-based sources, obtain approval from faculty on the resources selected.

Create and attach an APA-formatted reference page with the SOAP note. Case Study Evelyn Johnson
NRP/556 Version 1
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University of Phoenix Material
Case Study: Evelyn Johnson
In this case study, write a focused SOAP note addressing the patient’s concerns. The history must be
consistent with the exam, assessment, and plan. You will need to invent findings consistent with your
exam and diagnosis, but do not include any additional positive findings. Following the history, create a
chart that associates your working hypotheses with the list of rejected hypotheses you choose to include
in the history. This is to help you fine-tune what you include from the review of systems. Refer to the Case
Study Assignment Instructions for more information.
In your paper, explain certain aspects of the plan, including the medications that were started or stopped,
diagnostic tests ordered, and strategies recommended for health promotion and disease prevention. Do
not include education given to the patient, although this should be included in the plan. Include evidence
from the readings.
Identify the differences in practice that should be addressed while making the decisions needed to treat
this individual.
Evelyn Johnson a 40-year-old woman with a 10-year history of migraine headache was seen by another
provider in your office for c/o increased frequency of migraines over the past month. She could not tell the
provider if the migraines were all on one side or alternated temples. A stat MRI was completed yesterday
and was reported as normal.
Evelyn is in your office for results and management of her migraines. She is having two migraines per
week, unrelieved by two Fioricet® tablets, which had relieved them until recently. She finds herself taking
6 to 8 Fioricet® per migraine, hoping it will go away. She has not tried anything else. She becomes
nauseated with these migraines, has vomited on several occasions, and must be in a dark, quiet room to
relieve symptoms. She has missed work at least 1 day per week during the past month and her employer
is unhappy about her absences. She has no other medical problems. She had a partial hysterectomy 10
years ago for endometriosis. She is on no other medications. She does not smoke and stopped drinking
ETOH when the migraine frequency increased. Her caffeine consumption is two cups of coffee per day.
She denies other symptoms. Stress has been increased recently. Her company has been putting
pressure on her to increase her caseload and her boyfriend of 5 years recently ended the relationship.
Her last physical exam was 5 years ago.
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Grading Criteria
NRP/556 Version 1
University of Phoenix Material
Grading Criteria
Week 3: Evidence-Based Practice Case Studies: Evelyn Johnson
Content: 85 points possible
Points possible
Addresses chief complaint of visit, chronic health
problems from prior visits, and strategies for health
promotion and disease prevention.
7
Includes a focused history including previous history,
onset, location, duration, characteristics, associated
symptoms, relieving factors, timing, and severity.
8
Includes the exam with the working differentials as well
as any chronic problems that exist and is consistent
with the history and final diagnosis.
7
Includes confirmed diagnoses in the assessment
section and includes a section for differential
diagnoses that are seriously being considered and are
supported by the history and exam.
8
Includes an organized treatment plan that is evidencebased and promotes lawful practice based on the
federal and state regulations of where the student
resides or plans to practice.
20
Includes the following list of items in the plan:
• Medications to be started and discontinued
• Diagnostic tests
• Strategies for health promotion and disease
prevention
• Patient and family education
• Interval for follow-up
• Any diagnostic testing to be done prior to follow-up
• New prescription for each drug ordered, refills if
appropriate
35
Points earned
Copyright © 2018 by University of Phoenix. All rights reserved.
Comments
1
Grading Criteria
NRP/556 Version 1
Format: 15 points possible
Points possible
Accurate application of writing conventions enhanced
the content.
2
SOAP note is clear, logical, easy to follow, and
complete with appropriate content.
3
Accurately formatted paper using in-text citation and a
reference page that follows APA guidelines.
5
Includes a minimum of 5 relevant academic scholarly
sources.
5
Points earned
Comments
Points earned
Comments
Points earned/possible
/100
Week 4: i-Human Patients®: Mabel Johnson
Content: X points possible
Points possible
Consider the following:
Takes the patient’s history.
•
14
(35% of grade)
•
•
•
•
•
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Decide if the patient can be treated as an outpatient,
i.e., a focused case with fewer history questions
needed versus a patient who might be hospitalized
for treatment, i.e., comprehensive case where all
components of a history should be investigated.
Is there a prior chart to review?
Document the chief complaint
Document any abnormal history or complaints on
your problem list
The Interview Progress Button can be used up to 5
times to give you feedback on how close you are to
asking all “required questions” relevant to the chief
complaint.
It is highly recommended that you treat the patient
encounter like a real patient experience. The
questions you ask during the history interview
should be presented to the patient in an organized
and logical fashion.
2
Grading Criteria
NRP/556 Version 1
Content: X points possible
Points possible
Points earned
Comments
Consider the following:
Performs a physical exam.
14
(35% of grade)
•
•
•
Documents abnormal history and physical findings on
your problem list.
0
Vital signs are given.
Assess vital signs and perform the examination
appropriate for the type of case identified by the
above history. Remember the comprehensive cases
require a comprehensive physical.
Document abnormal findings in your problem list.
Although this section is not graded, it is highly
encouraged for practice and must be completed to
progression through the case player.
Consider the following:
Writes a concise problem statement.
•
•
0
•
Start with a demographic description of your
patient and the chief complaint and MSAP.
Try to keep your problem statement below 100
words.
Although this will not count towards your final
case score, it will allow you to practice learning
to communicate patient information in a
complete and concise fashion.
Note: Although this section is not graded, it is highly
encouraged for practice and must be completed to
progression through the case player.
Consider the following:
Completes differential diagnosis list.
•
0
•
You may start thinking about your differential
diagnosis during the history taking section, but
after completing the problem statement, reflect
and finalize your differential diagnosis list.
Make sure the list is comprehensive. The
average list contains 5 diagnoses.
Note: Although this section is not graded, it is highly
encouraged for practice and must be completed to
progression through the case player.
Reviews tests results.
Orders Tests (10% of grade).
4
(10 % of grade)
4
Consider the following:
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Grading Criteria
NRP/556 Version 1
Content: X points possible
Points possible
Points earned
•
•
(10% of grade)
Selects a final diagnosis (10% of grade).
Comments
Order each test and link it to a diagnosis.
Some tests are ordered to “rule in” a diagnosis while
others are ordered to “rule out” a diagnosis.
4
(10% of grade)
Develops a treatment plan as described by your course
instructor (0% of grade).
Note: Although this section is not graded, it is highly
encouraged for practice and must be completed to
progression through the case player.
0
Points earned/possible
/40
Week 4: Human Patients® Mabel Johnson – Reflection
Content: 32 points possible
Points possible
Provides a summarize of the expert feedback received
from the Mabel Johnson case.
8
Identifies areas of improvement in your patient
encounter that reflects in the feedback from the expert
and the article selected.
7
Explains potential techniques in the article that can be
used to improve clinical skills, if applicable.
5
Evaluates theories from the article that can guide
clinical decision making or considers questions that
might be answered through theories from nursing and
other disciplines.
7
Explains how the information from the patient encounter
and the article can be applied in the clinical setting.
5
Format: 8 points possible
Points possible
Accurately formatted paper using in-text citation and a
reference page that follows APA guidelines.
Points earned
Comments
Points earned
Comments
2
Copyright © 2018 by University of Phoenix. All rights reserved.
4
Grading Criteria
NRP/556 Version 1
Format: 8 points possible
Points possible
Includes at least one relevant academic article that
aligns to the conditions presented in the Mabel Johnson
case.
3
Accurate application of writing conventions enhanced
the content.
3
Points earned
Comments
Points earned/possible
/40
Week 5: Programmatic Assessment Clinical Management Presentation
Content: 150 points possible
Points possible
Points earned
Comments
Points possible
Points earned
Comments
See rubric in course.
Points earned/possible
/150
Week 7: Evidence-Based Practice Paper
Content: 140 points possible
Provides an introduction
5
Includes occurance, etiology, and pathology
20
Includes morbidity and mortality
20
Includes diagnostic testing
20
Includes diagnosis
20
Includes management, clinical preventive services and
treatment plan that utilizes Watson’s theory.
45
Provides a conclusion
10
Copyright © 2018 by University of Phoenix. All rights reserved.
5
Grading Criteria
NRP/556 Version 1
Format: 40 points possible
Points possible
Points earned
Follows rules of grammar, usage, and punctuation
Structure is clear, logical, and easy to follow
Follows APA formatting and citation guidelines
40
Meets the required word count (1,200 words)
Cites the required number of sources (8 sources)
Points earned/possible
/180
Copyright © 2018 by University of Phoenix. All rights reserved.
Comments
6
Sample SOAP Note
NRP/556 Version 1
1
University of Phoenix Material
Sample SOAP Note
CC: Dizziness and nocturia x 2
S: Patient comes in today with complaints of dizziness. This started approximately 2 days ago, is present
at all times, and is described as a spinning sensation. It is worse with head movement and improved
when still. Symptoms are associated with nausea and vomiting, but patient denies headache, syncope,
near-syncope, or visual changes. Patient has also had nocturia for the last 3 weeks, which has disturbed
his sleep. He states getting up twice at night to urinate a moderate amount, but has had no increase in
daytime urination. This nocturia is aggravated by increased fluid intake and alleviated by avoiding fluids
after 6 p.m. There are no associated symptoms. He denies any hesitancy, dysuria, hematuria, or
decreased urine stream.
O: WT 250 BP 148/98 P 88 T 98.6. Glucometer in the office is 260 (nonfasting). Patient is a middle-aged,
slightly obese male that appears in no acute distress. Neuro: PERLLA with CN I-CNXII normal bilaterally.
TM intact bilat with no erythema. No sinus tenderness noted. Nares red with no drainage noted. Throat no
erythema or tonsilar enlargement/exudates. No nystagmus noted with EOMs intact. Lungs are CTA with
good and equal bilateral breath sounds and equal chest expansion. Normal A/P diameter. Heart RRR
with no murmur, rub, or extra heart sounds. PMI is nondisplaced, S1 and S2 are audible and regular.
Penis is circumcised with no urethral irregularities noted. Patient has two testicles, both descended with
no lesions or irregularities palpated. Prostate exam shows normal +1 boggy-feeling prostate with no
lumps or irregularities.
A:
386.11 Benign Positional Vertigo
788.43 Nocturia, suspect DM
401.9 Hypertension, not controlled
272.4 Dyslipidemia
Comprehensive Office Visit – CPT Code: 99214
Differentials
Unsupported information
TIA
No neurological abnormalities to support this
Sinusitis
No fever, physical exam does not support
Arrhythmia
Pulse regular, symptoms aggravated with
movement and are not even related
Plan
Rationale and EBP/supporting documentation
Attempt Canalith repositioning maneuver in office
Epley maneuver is suggested first-line treatment
for BPV and has been shown to be 70% effective
(Fife et al., 2008).
Teach patient Epley maneuver for home use
By teaching patients correct procedure, they may
get relief of sx more rapidly.
Meclizine 25 mg TID-QID PRN dizziness #45 with
0 refills
American College of Audiologist suggests
meclizine as second-line tx for BPV. It is indicated
for BPV (PDR, 2008).
OGTT or fasting BS this week
ADA recommends screening for DM in someone
with nocturia (ADA, 2009).
Urine analysis
Consider a UTI as a differential.
Copyright © 2018, 2017, 2016, 2015, 2013 by University of Phoenix. All rights reserved.
Sample SOAP Note
NRP/556 Version 1
Reinstruct on the importance of diet and exercise
American Task Force on Healthy Americans
suggests this (AHRQ, 2008).
Home BP monitoring for 2 weeks, results to office
According to AHA, diagnosis for HTN should
include monitoring ambulatory BPs (White, 2006).
Suggest no fluids after 6 p.m.
To help with symptoms of nocturia
Referral for colonoscopy
Task force recommendation for anyone over 50
(AHRQ, 2008)
Follow up in 1 week
Need to reevaluate symptoms and review lab
testing.
References
Agency for Healthcare Research and Quality. (2008). Guide to clinical preventive services, 2009.
Retrieved from http://www.ahrq.gov/clinic/pocketgd09/
American Diabetes Association. (January, 2009). Summary of revisions for the 2009 clinical practice
recommendations. Diabetes Care, 32. Retrieved from
http://care.diabetesjournals.org/content/32/Supplement_1/S3.full
Fife, T. D., Iverson, D. J., Lempert, T., Furman, J. M., Baloh, R. W., Tusa. R. J., Gronseth, G. S. (2008).
Practice parameter: Therapies for benign paroxysmal positional vertigo (an evidence-based review):
Report of the Quality Standards Subcommittee of the American Academy of Neurology. Neurology,
70(22) 2067–2074. Retrieved from http://www.neurology.org/cgi/content/full/70/22/2067
Physicians’ Desk Reference. (2008). Meclizine. Retrieved from
http://www.pdr.net/druginformation/FDAMonographsInfo.aspx?MonographID=1059
White, W. (2006). Expanding the use of ambulatory blood pressure monitoring for the diagnosis and
management of patients with hypertension. Hypertension, 47 14–15. Retrieved from
http://hyper.ahajournals.org/cgi/content/full/47/1/14
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