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NU 610 Unit 1 - Case Studies Instructions Review the following case studies

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NU 610 Unit 1 - Case Studies

Instructions

• Review the following case studies.
• In a Word file construct a subjective data set for each case from the information provided.  
• Structure the subjective data set in the format provided in your lecture materials.  
• Submit the Word file containing your 3 subjective data sets into Canvas.
• To support your success on the assignment the SOAP Note Assignment Instructions are attached here for your review of how to structure a subjective data set.

NU610 Unit 1 Assignment - Case Studies Rubric

NU610 Unit 1 Assignment - Case Studies Rubric

Criteria	Ratings	Pts
This criterion is linked to a Learning OutcomeSubjective Data	40 pts Highly Proficient Elements of subjective data (CC, HPI, PMH, Allergy identification, Medication Reconciliation, Social History, Family History, Health Promotion, and ROS) are well written with few to no omissions or misclassifications of data from the case for all 3 cases. 32 pts Proficient Elements of subjective data (CC, HPI, PMH, Allergy identification, Medication Reconciliation, Social History, Family History, Health Promotion, and ROS) are well written with few to no omissions or misclassifications of data from the case for 2 of the 3 cases. 24 pts Marginally Proficient Elements of subjective data (CC, HPI, PMH, Allergy identification, Medication Reconciliation, Social History, Family History, Health Promotion, and ROS) are well written with few to no omissions or misclassifications of data from the case for 1 of the 3 cases. 16 pts Approaching Proficiency Elements of subjective data (CC, HPI, PMH, Allergy identification, Medication Reconciliation, Social History, Family History, Health Promotion, and ROS) are documented partially correct for all of the cases. 8 pts Not Proficient Elements of subjective data (CC, HPI, PMH, Allergy identification, Medication Reconciliation, Social History, Family History, Health Promotion, and ROS) are not documented partially correct for any of the cases. 0 pts Not Evident An assignment submission is not located.	40 pts
Total Points: 40

 

NU610 Unit 1 Case Studies
Case 1
A 50-year-old man comes to your office for a routine physical examination. He is a new patient to your
practice. He states his father died at the age of 73 of a heart attack. His mother is alive at the age of 80.
He has hypertension, which he takes chlorthalidone 25 mg PO daily. Takes Tylenol as needed for pain.
Denies seasonal or drug allergies. He has two younger siblings with no known chronic medical
conditions. Last eye and dental exam two years ago. He is married in a monogamous relationship
without children. Has a high school diploma. Works full-time for local landscaping business. He does
not smoke, drink alcohol, use any recreational drugs and does not exercise. He denies fever, chills,
weight loss or weight gain. He denies hearing changes, headaches or dizziness. He reports some visual
changes when reading close-up. He denies shortness of breath, dyspnea on exertion, swelling or chest
pain. He reports increase urination and thirst. Denies abdominal pain, nausea, vomiting or changes in
appetite. He reports daily BM. Denies rashes or bug bites. Uses sunscreen daily due to working
outside. Denies anxiety or depression. On examination his blood pressure is 126/82, pulse is 80
beats/min, respiratory rate is 18. Height is 67 inches and weight is 190lbs. Does not appear in acute
distress, responses are appropriate and appears reliable source. Alert, oriented to person, place, time
and situation. Well-nourished, skin warm, dry and intact. Normocephalic. Pupils size 3 mm, equal and
reactive to light. Extraocular eye movements intact to six directions. Tympanic membranes gray with
adequate cone of light bilaterally. Mucous membranes pink and moist. No palpable masses,
thyromegaly, lymphadenopathy or JVD. Regular heart rate and rhythm, S1 and S2. No bruits
auscultated. Capillary refill less than 3 seconds. Breath sounds clear bilaterally to auscultation. No use
of accessory muscles or purse lip-breathing. Soft, non-tender, non-distended, normoactive bowel
sound. No organomegaly or guarding. Denies numbness or tingling. He reports he has not had HIV or
PSA screenings.
Case 2
A 40-year-old woman presents with 10 episodes of watery, non-bloody diarrhea that started last night.
She vomited twice last night but has been able to tolerate liquids today. She is complaining of
intermittent abdominal cramping, rating pain 4 out of 10. She also reports having muscle aches,
weakness, headache, and low-grade fever of 99.7 at home. She states her son has had the same
symptoms that started this morning. She has no significant medical history, denies surgeries, and does
not take any prescribed medications. Last wellness examination was 2 years ago when cervical screening
was completed. She does not smoke, use alcohol, or illicit drugs. She does report that her and her family
returned home yesterday after spending a week in Cancun. On examination she is not in acute distress,
blood pressure is 110/60, pulse 98, respiratory rate is 16, and temperature is 99.1. Bowel sounds are
hyperactive, and her abdomen is mildly tender throughout but there is no rebound tenderness and no
guarding. Her mucous membranes are dry. A rectal examination is normal, and stool is guaiac negative.
Reports trying Pepto-Bismol this morning without relief. Denies food, seasonal or drug allergies. Last
menses 3 weeks ago, currently single and not sexually active. Heart rate regular rate and rhythm with
S1 and S2. Breath sounds clear to auscultation bilaterally with symmetrical chest expansion. Alert and
oriented, does not appear acutely ill. Needs a work excuse, works part-time at community college.

 

Case 3
A 40-year-old single male presents to your office complaining of left knee pain that has started last
night. He says that the pain started suddenly and was severe within about 3 hours’ time. He denies
injury, fever, systemic symptoms, or prior episodes. He has a history of hypertension and does take
hydrochlorothiazide 12.5 mg PO daily to control it. He admits to consuming a large amount of wine with
dinner last night. He currently is not working. Has allergy to Percocet which he reports reaction is
urticaria. Upon examination his temperature is 98, pulse is 90, respirations are 22 and blood pressure is
129/88. Heart and lung examinations are unremarkable. The patient is reluctant to flex the left knee and
does wince with pain at touch. He has passive range of motion. The knee is edematous, hot to touch,
and has erythema of the overlying skin. No crepitation or deformity is apparent. No other joints are
involved. Inguinal lymph notes are not enlarged. He denies trauma or previous injury to his left knee.
He denies weight loss or weight gain. He reports in the past having swelling to his big toe that went
away on its own. He tried ibuprofen without relief of the pain this morning. Rates the pain about six
out of ten that is constant. Denies any family history of joint or musculoskeletal issues. He denies
smoking or illicit drug use. Was recently seen in the office 6 months ago for wellness exam with normal
blood pressure reading and A1c. He is alert and oriented to self, place, time and situation. Well-
nourished on exam reports eating keto diet. Thoughts are coherent, mood and affect appropriate.

SOAP Note Assignment Instructions

Consider constructing a Word document ‘SOAP note template’ and use it to assemble your
note. By doing this you can use the template for efficiently constructing your SOAP notes such
that you will be able to copy-and-paste for your weekly assignments. NOTE: If your faculty
person requests to see your SOAP note template you will be required to send it to them for
review.
All sections of the SOAP note should be addressed relevant to the presenting chief complaint.
Subjective (S):
CC: chief complaint - What are they being seen for? This is the reason that the patient sought
care, stated in their own words/words of their caregiver, or paraphrased.
HPI: history of present illness - use the “OLDCART” approach for collecting data and
documenting findings. [O=onset, L=location, D=duration, C=characteristics,
A=associated/aggravating factors, R=relieving factors, T=treatment, S=summary]
PMH: past medical history - This should include past illness/diagnosis, conditions, traumas,
hospitalizations, and surgical history. Include dates if possible.
Allergies: State the offending medication/food and the reactions.
Medications: Names, dosages, and routes of administration.
Social history: Related to the problem, educational level/literacy, smoking, alcohol, drugs, HIV
risk, sexually active, caffeine, work and other stressors. Cultural and spiritual beliefs that impact
health and illness. Financial resources.
Family history: Use terms like maternal, paternal and the diseases and the ages they were
deceased or diagnosed if known.
Health Maintenance/Promotion - Required for all SOAP notes: Immunizations, exercise, diet,
etc. Remember to use the United States Clinical Preventative Services Task Force (USPSTF)
guidelines for age appropriate indicators. This should reflect what the patient is presently doing
regarding the guidelines.
ROS: review of systems - [Refer to your course modules and the Bickley Etext (Bates Guide) as a
guide when conducting your ROS to make sure you have not missed any important symptoms,
particularly in areas that you have not already thoroughly explored while discussing the history
of present illness. ]
You would also want to include any pertinent negatives or positives that would help with your
differential diagnosis. For acute episodic (focused) visits (i.e. sorained ankle, sore throat, etc.)
you may be omitting certain areas such as GYN, Rectal, Gl/Abd, etc. While the list below is

provided for your convenience it is not to be considered all-encompassing and you are
expected to include other systems/categories applicable to your patient’s chief complaint.
General: May include if patient has had a fever, chills, fatigue, malaise, etc.

Skin:

HEENT: head, eyes, ears, nose and throat

Neck:

CV: cardiovascular

Lungs:

Gl: gastrointestinal

GU: genito-urinary

PV: peripheral vascular

MSK: musculoskeletal

Neuro: neurological

Endo: endocrine

Psych:

Objective (O):

PE: physical exam - [Refer to your course modules and the Bickley Etext (Bates Guide) as a
guide when determining what physical assessments, you want to include to further explore
what you have learned from your subjective data collection]

Perform either a focused exam or comprehensive exam to ensure a comprehensive physical
assessment.

This area should confirm your findings related to the diagnosis. For acute episodic (focused)
visits (i.e. sprained ankle, sore throat, etc.) you may be omitting certain areas such as GYN,
Rectal, Abd, etc. All SOAP notes however should have physical examination of CV and lungs.
Ensure that you include appropriate male and female specific physical assessments when
applicable to the encounter. Your physical exam information should be organized using the
same body system format as the ROS section. Appropriate medical terminology describing the
objective examination is mandatory.

While the list below is provided for your convenience it is not to be considered all-
encompassing and you are expected to include other systems/assessments applicable to your
patient’s chief complaint.

Gen: general statement of appearance, if there is any acute distress.
VS: vital signs, height and weight, BMI
Skin:
HEENT: head, eyes, ears, nose and throat
Neck:
CV: cardiovascular
Lungs:
Abd: abdomen
GU: genito-urinary
PV: peripheral vascular
MSK: musculoskeletal
Neuro: neurological exam
Diagnostic Tests: This area is for tests that were completed during the patient’s appointment
that ruled the differential diagnosis in or out (e.g. — Rapid Strep Test, CXR, etc.).
Assessment (A):
Diagnosis/Diagnoses: Start with the presenting chief complaint diagnosis first. Number each
diagnosis.
A statement of current condition and all other chronic illnesses that were addressed during the
visit must be included (i.e. HTN-well managed on medication).
Remember the data you provide in the ‘S’ data set and the ‘O’ data set must support this
diagnosis (or these diagnoses if more than one is listed). Pertinent positives and negatives must
be found in the write-up.
Plan (P):
These are the interventions that relate to each individual, numbered diagnosis.
Document individual plans directly after each corresponding assessment (Ex. Assessment-
Plan). Address the following aspects (they should be separated out as listed below):
Diagnostics: labs, diagnostics testing - tests that you planned for/ordered during the encounter
that you plan to review/evaluate relative to your work up for the patient’s chief complaint.

Therapeutic: changes in meds, skin care, counseling, include full prescribing information for any
pharmacologic interventions including quantity and number of refills for any new or refilled
medications.
Educational: information clients need in order to address their health problems. Include follow-
up care. Anticipatory guidance and counseling.
Consultation/Collaboration: referrals, or consult while in clinic with another provider. If no
referral made was there a possible referral you could make and why? Advance care planning.
NOTE: please input N/A where appropriate for the above 4 categories, do not assume that your clinical faculty person will know it was not applicable