ASSESSING, DIAGNOSING, AND TREATING MUSCULOSKELETAL AND NEUROLOGIC DISORDERS
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.
Case Study: CVA
HPI:
Mario is a 66-year-old Hispanic male who presents to the emergency room at his local hospital with acute aphasia, right facial droop, and right-sided weakness. The sudden onset of symptoms occurred at the post office where he works part time. One of his co-workers called 911. On the way to the hospital, the advanced squad team evaluated Mario’s neurologic deficits and glucose levels. The squad team then notified the receiving hospital of a possible stroke patient.
Upon Mario’s arrival to the hospital, the ER nurse practitioner proceeds to gather the patient’s medical history from his wife, Lucinda, who accompanied him in the ambulance. She tells the nurse practitioner that Mario has a history of uncontrolled hypertension (and he was often non-compliant with his anti-hypertensive medications). His recent diagnosis of diabetes also was noted, as well as the oral hyperglycemic agents he was taking.
The wife states both of Mario’s parents passed away from myocardial infarctions when they were in their late 60s.
Smoking history: Mario is a smoker, usually smoking about a pack and a half each day.
Exercise history: Mario leads a sedentary lifestyle that had contributed to his excess weight.
At 5’5” inches, Mario weighs 255 pounds. BMI of: ____ You decide what his VS are.
What other family history, social history, and vital signs will you obtain from the wife and the patient? Also: the HPI is the history of the present illness – not a place for everything. OLDCARTS go in HPI.
If it is in the HPI: do not repeat it in the ROS or PE, just say “see HPI” The soap note should be as succinct as possible. This means the Social history should be short – only mention things that might highlight the patient’s current condition or lifestyle.
Remember to document the ROS and PE findings as you would for a real patient / or one you have had in the past. DO NOT write “not done” or “normal.” This is not acceptable. However, if you write for the rectal exam “deferred” this is acceptable.
What diagnostic tests will you order for Mario to determine what type of stroke he is having? List at least four diagnostic tests you would order and explain the rationale of each test.
The CT scan indicated a diagnosis of stroke. However, the lab tests and CT scan performed on Mario indicated there was no hemorrhage or early signs of ischemia. What education can you provide the family about the results of a CT scan for diagnosis of brain stroke?
You tell Mario’s wife that it is crucial to recognize the signs of an impending stroke. Describe at least four symptoms and signs of stroke you will educate the patient and family to look for.
Also discuss the RISK factors for stroke with Mario’s family. Lucinda realizes that Mario meets the criteria for all of them.
List at least four risk factors for having a stroke:
List at least three differential diagnoses for the symptoms listed above:
What referrals will you make for Mario after his stroke? List at least three.
Include health promotion education you will provide to Mario and his wife.
