NRNP 6540 Psychosocial Disorders Assessing Diagnosing and Treating Dementia Delirium and Depression Assignment Example
NRNP 6540 Psychosocial Disorders Assessing, Diagnosing, and Treating Dementia, Delirium, and Depression Assignment
NRNP 6540 Psychosocial Disorders Assessing, Diagnosing, and Treating Dementia, Delirium, and Depression Assignment Brief
Course: NRNP 6540 – Advanced Practice Care of Older Adults
Assignment Title: NRNP 6540 Psychosocial Disorders Assessing, Diagnosing, and Treating Dementia, Delirium, and Depression Assignment
Assignment Instructions Overview
This assignment focuses on assessing, diagnosing, and treating dementia, delirium, and depression in geriatric patients. It requires completion of a SOAP (subjective, objective, assessment, and plan) note based on a provided case study.
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Understanding Assignment Objectives
You will evaluate a geriatric patient presenting with symptoms of dementia, delirium, or depression, develop differential diagnoses, and create treatment plans inclusive of diagnostic testing and therapeutic interventions.
The Student’s Role
As an advanced practice nurse, your role involves accurately documenting patient history, conducting thorough physical assessments, and interpreting diagnostic results to formulate effective treatment plans.
Competencies Measured
This assignment assesses your ability to:
- Evaluate geriatric patients for psychosocial disorders.
- Develop differential diagnoses based on clinical findings.
- Design comprehensive treatment plans aligned with evidence-based guidelines.
- Demonstrate effective communication skills through documentation.
You Can Also Check Other Related Assessments for the NRNP 6540 – Advanced Practice Care of Older Adults Course:
NRNP 6540 Assessment of Older Adults Evaluation Plan Discussion Example
NRNP 6540 Psychosocial Disorders Assessing Diagnosing and Treating Dementia Delirium and Depression Assignment Example
NRNP 6540 Assessing Cardiovascular and Pulmonary Disorders Assignment Example
NRNP 6540 Assessing Diagnosing and Treating Abdominal Urological and Gynecological Disorders Assignment Example
NRNP 6540 Assessing Diagnosing and Treating Hematological and Immune System Disorders Assignment Example
NRNP 6540 Psychosocial Disorders Assessing Diagnosing and Treating Dementia Delirium and Depression Assignment Example
Patient Information:
Ms. P, 70-year-old female, Caucasian
Subjective:
Chief Complaint (CC):
Increased confusion, agitation, and restlessness.
History of Present Illness (HPI):
Ms. P is a 70-year-old female with a known history of dementia, managed with Aricept (Donepezil) 10 mg daily. She presented with acute confusion, more than usual, and increased agitation and restlessness over the past two days. Two days ago, she became more disoriented and yesterday, she could not remember where she was in her own home. Her son, Jared, reports these changes began after her HCTZ dosage was increased to 50 mg three days ago. No falls, traumas, changes in diet or routine, dysuria, fever, nausea, or vomiting reported. Last MMSE score was 18/30, which remained unchanged today.
Current Medications:
- Multivitamin daily
- Losartan 50 mg daily
- HCTZ 50 mg daily (recently increased)
- Fish Oil 1 tablet daily
- Glyburide 5 mg daily
- Metformin 500 mg BID
- Donepezil 10 mg daily
- Alendronate 70 mg orally once a week
Allergies:
- Atorvastatin (angioedema)
Past Medical History (PMHx):
- Hypertension
- Diabetes
- Osteoporosis
- Chronic allergic rhinitis
Review of Systems (ROS):
- General: No weight loss, fever, chills, weakness, or fatigue.
- Head: No headache or trauma.
- Eyes: No visual loss, blurred vision, or double vision.
- Ears, Nose, Throat (ENT): No hearing loss, sneezing, congestion, or sore throat.
- Cardiovascular: No chest pain, pressure, discomfort, or palpitations.
- Respiratory: No shortness of breath, cough, or sputum.
- Gastrointestinal: No anorexia, nausea, vomiting, or diarrhea. No abdominal pain or blood in stool.
- Genitourinary: No dysuria. LMP: N/A.
- Neurological: Increased confusion and agitation. No dizziness, syncope, paralysis, or ataxia.
- Musculoskeletal: No muscle pain or joint stiffness. Some balance issues but no falls.
- Psychiatric: No history of depression or anxiety. No suicidal ideation.
- Endocrinologic: No sweating, cold or heat intolerance. No polyuria or polydipsia.
- Reproductive: Not pregnant, not sexually active.
- Allergies: No history of asthma, hives, eczema, or rhinitis.
Objective:
Vital Signs:
- Temperature: 98.1°F
- Blood Pressure: 120/64 mmHg
- Heart Rate: 72 bpm
- Respiratory Rate: 20 bpm
Physical Exam:
- General: Alert but easily distracted.
- Head: Normocephalic, atraumatic.
- Eyes: PERRLA (pupils equal, round, reactive to light and accommodation), no nystagmus.
- ENT: Oral mucosa moist, no lesions.
- Neck: Supple, no lymphadenopathy.
- Cardiovascular: Regular rate and rhythm, no murmurs or gallops.
- Respiratory: Clear to auscultation bilaterally.
- Abdomen: Soft, non-tender, no hepatosplenomegaly.
- Musculoskeletal: No joint swelling or deformities. Balance issues noted.
- Neurological: Alert but disoriented to place and time, speech clear but tangential.
- Psychiatric: No visual or auditory hallucinations, denies suicidal ideation.
Diagnostic Results:
- CXR: No cardiopulmonary findings. WNL.
- CT Head: Diffuse cerebral atrophy.
- MMSE: 18/30, indicating moderate dementia.
- Hemoglobin A1C: 7.2%
- Basic Metabolic Panel:
- Glucose: 90 mg/dL
- Sodium: 130 mmol/L (low)
- Potassium: 3.4 mmol/L (low)
- Chloride: 104 mmol/L
- CO2: 29 mmol/L
- Calcium: 9.0 mg/dL
- BUN: 20 mg/dL
- Creatinine: 1.00 mg/dL
- eGFR: 77 mL/min/1.73m2
Assessment:
Primary Diagnosis:
- Delirium – Acute onset of confusion, agitation, and restlessness in a patient with baseline dementia, likely precipitated by a medication change (increased HCTZ).
Differential Diagnoses:
- Worsening Dementia – Progressive confusion and disorientation typical of dementia; however, acute exacerbation suggests an additional factor.
- Electrolyte Imbalance (Hyponatremia and Hypokalemia) – Low sodium and potassium levels could contribute to confusion and agitation.
Plan:
Diagnostics:
- Repeat electrolytes in 48 hours to monitor for further changes.
- Consider urinalysis to rule out UTI, which could exacerbate confusion.
Medications:
- Review and potentially adjust HCTZ dosage considering recent increase and onset of symptoms.
- Consider switching HCTZ to an alternative antihypertensive not listed on the Beers Criteria for elderly patients.
Therapeutic Interventions:
- Hydration to correct potential dehydration contributing to electrolyte imbalance.
- Cognitive stimulation activities tailored to dementia patients.
Referrals:
- Referral to a neurologist for further evaluation of dementia progression.
- Referral to a dietitian to assess and manage nutritional needs impacting blood glucose and electrolytes.
Education:
- Educate son on signs of delirium versus dementia exacerbation and importance of medication adherence and monitoring.
Follow-Up:
- Follow-up visit in one week to reassess symptoms and evaluate lab results.
- Immediate follow-up if symptoms worsen.
Health Promotion and Disease Prevention:
- Encourage a balanced diet to manage diabetes and blood pressure.
- Regular physical activity to improve balance and overall health.
- Ensure home safety modifications to prevent falls.
Reflection:
This case highlights the importance of monitoring medication changes and their impact on elderly patients, particularly those with dementia. The overlap of symptoms between dementia, delirium, and other medical conditions necessitates a comprehensive and multidisciplinary approach to patient care.
References
American Geriatrics Society. (2019). Updated Beers Criteria for Potentially Inappropriate Medication Use in Older Adults. Journal of the American Geriatrics Society, 67(4), 674-694.
Inouye, S. K., Westendorp, R. G. J., & Saczynski, J. S. (2014). Delirium in elderly people. Lancet, 383(9920), 911-922.
Marcum, Z. A., & Hanlon, J. T. (2012). Commentary on the New American Geriatrics Society Beers Criteria for Potentially Inappropriate Medication Use in Older Adults. The American Journal of Geriatric Pharmacotherapy, 10(2), 151-159.
Detailed Assessment Instructions for the NRNP 6540 Psychosocial Disorders Assessing, Diagnosing, and Treating Dementia, Delirium, and Depression Assignment
Week 2: Psychosocial Disorders
In so many countries, to be old is shameful; to be mentally ill as well as old is doubly shameful. In so many countries, people with elderly relatives who are also mentally ill are ashamed and try to hide what they see as a disgrace on the family.
—Dr. Nori Graham, Psychiatrist and Honorary Vice President of Alzheimer’s Disease International
In this quote, Dr. Graham is expressing her observations and experiences in her work with numerous international organizations. Many patients and their families experience feelings of anxiety and shame upon receiving a diagnosis of dementia, delirium, or depression. Among caregivers, 36% report having tried to hide the dementia diagnosis of their family member (Alzheimer’s Disease International, 2019). As an advanced practice nurse providing care to patients presenting with dementia, delirium, and depression, it is critically important to consider the impact of these disorders on patients, caregivers, and their families. A thorough understanding of the health implications of these disorders, as well as each patient’s personal concerns, will aid you in making effective treatment and management decisions.
This week, you explore geriatric patient presentations of dementia, delirium, and depression. You also examine assessment, diagnosis, and treatment for these disorders and complete a SOAP (subjective, objective, assessment, and plan) note.
Reference:
Alzheimer’s Disease International. (2019). World Alzheimer report 2019: Attitudes to dementia. Author. https://www.alz.co.uk/research/world-report-2019
Learning Objectives
Students will:
- Evaluate patients presenting with symptoms of dementia, delirium, or depression
- Develop differential diagnoses for patients with psychosocial disorders
- Develop appropriate treatment plans, including diagnostics and laboratory orders, for patients with psychosocial disorders
Assignment: Assessing, Diagnosing, and Treating Dementia, Delirium, and Depression
Photo Credit: Getty Images
With the prevalence of dementia, delirium, and depression in the growing geriatric population, you will likely care for elderly patients with these disorders. While many symptoms of dementia, delirium, and depression are similar, it is important that you are able to identify those that are different and properly diagnose patients. A diagnosis of one of these disorders is often difficult for patients and their families. In your role as an advanced practice nurse, you must help patients and their families manage the disorder by facilitating necessary treatments, assessments, and follow-up care.
To prepare:
- Review the case study provided by your Instructor. Reflect on the way the patient presented in the case, including whether the patient might be presenting with dementia, delirium, or depression.
- Reflect on the patient’s symptoms and aspects of disorders that may be present. What distinct symptoms or factors would lead you to a diagnosis of dementia, delirium, or depression?
- Consider how you might assess, perform diagnostic tests, and recommend medications to treat patients presenting with the symptoms in the case.
- Access the Focused SOAP Note Template in this week’s Resources.
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? How would you interpret and address the results of the Mini-Mental State Examination (MMSE)?
- 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 healthcare 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.
Reminder: The College of Nursing requires that all papers submitted include a title page, introduction, summary, and references. The Sample Paper provided at the Walden Writing Center provides an example of those required elements (available at http://writingcenter.waldenu.edu/57.htm). All papers submitted must use this formatting.
By Day 7
Learning Resources
-
- Kennedy-Malone, L., Martin-Plank, L., & Duffy, E. (2019). Psychosocial disorders. In Advanced practice nursing in the care of older adults (2nd ed., pp. 428–469). F. A. Davis.
- Kennedy-Malone, L., Martin-Plank, L., & Duffy, E. (2019). Appendix B: Laboratory values in the older adult. In Advanced practice nursing in the care of older adults (2nd ed., pp. 505–506). F. A. Davis.
- Note: See the labs that are relevant to this week’s topics.
- Laske, R. A., & Stephens, B. A. (2018). Confusion states: Sorting out delirium, dementia, and depression. Nursing Made Incredibly Easy!, 16(6), 13–16. https://doi.org/10.1097/01.NME.0000546254.38666.1f
- NIH National Institute on Aging. (2017). Basics of Alzheimer’s disease and dementia: What is Alzheimer’s disease? [Multimedia file]. https://www.nia.nih.gov/health/what-alzheimers-disease
-
Rubric Detail Tutor needs to FOLLOW
Select Grid View or List View to change the rubric’s layout.
Name: NRNP_6540_Week2_Assignment_Rubric
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Excellent |
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Fair |
Poor |
| Create documentation in the Focused SOAP Note Template about the patient in the case study to which you were assigned.
In the Subjective section, provide:
• Chief complaint
• History of present illness (HPI)
• Current medications, checked against Beers Criteria
• Allergies
• Patient medical history (PMHx)
• Review of systems |
9 (9%) – 10 (10%)
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. |
|
7 (7%) – 7 (7%)
The response 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, but is somewhat vague or contains minor innacuracies. A cross-check of medications against the Beers Criteria has been completed but alternatives may be missing. |
0 (0%) – 6 (6%)
The response provides an incomplete or inaccurate description of 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 cross-check of medications against the Beers Criteria has not been completed. Or, subjective documentation is missing. |
In the Objective section, provide:
• Physical exam documentation of systems pertinent to the chief complaint, HPI, and history
• Diagnostic results, including any labs, imaging, or other assessments needed to develop the differential diagnoses |
9 (9%) – 10 (10%)
The response thoroughly and accurately documents the patient’s physical exam for pertinent systems. Diagnostic tests and their results are thoroughly and accurately documented. |
|
7 (7%) – 7 (7%)
Documentation of the patient’s physical exam is somewhat vague or contains minor innacuracies. Diagnostic tests and their results are documented but contain minor innacuracies. |
0 (0%) – 6 (6%)
The response provides incomplete or inaccurate documentation of the patient’s physical exam. Systems may have been unnecessarily reviewed, or, objective documentation is missing. |
In the Assessment section, provide:
• At least three (3) differentials with supporting evidence. Explain what rules each differential in or out, and justify your primary diagnosis selection. Include pertinent positives and pertinent negatives for the specific patient case. |
23 (23%) – 25 (25%)
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. |
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18 (18%) – 19 (19%)
The response lists three possible conditions for a differential diagnosis of the patient in the assigned case study, with some vagueness and/or inaccuracy in the conditions and/or justification for each. |
0 (0%) – 17 (17%)
The response lists two or fewer, or is missing, possible conditions for a differential diagnosis of the patient in the assigned case study, with inaccurate or missing justification for each condition selected. |
In the Plan section, provide:
• A detailed treatment plan for the patient that addresses each diagnosis, as applicable. Includes documentation of diagnostic studies that will be obtained, referrals to other health-care providers, therapeutic interventions, education, disposition of the patient, and any planned follow up visits.
• A discussion related to health promotion and disease prevention taking into consideration patient factors, PMH, and other risk factors.
• Reflections on the case describing insights or lessons learned. |
27 (27%) – 30 (30%)
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. |
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21 (21%) – 23 (23%)
The response somewhat vaguely or inaccurately outlines a treatment plan for the patient. The discussion on health promotion and disease prevention related to the case is somewhat vague or contains innaccuracies. Reflections on the case demonstrate adequate understanding of course topics. |
0 (0%) – 20 (20%)
The response does not address all diagnoses or is missing elements of the treatment plan. The discussion on health promotion and disease prevention related to the case is vague, innaccurate, or missing. Reflections on the case are vague or missing. |
| 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. |
9 (9%) – 10 (10%)
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. |
. |
7 (7%) – 7 (7%)
Three evidence-based resources are provided to support treatment decisions, but may not represent the latest in standards of care or may only provide vague or weak justification for the treatment plan. |
0 (0%) – 6 (6%)
Two or fewer resources are provided to support treatment decisions. The resources may not be current or evidence-based, or do not support the treatment plan. |
Written Expression and Formatting—Paragraph Development and Organization:
Paragraphs make clear points that support well-developed ideas, flow logically, and demonstrate continuity of ideas. Sentences are carefully focused–neither long and rambling nor short and lacking substance. A clear and comprehensive purpose statement and introduction are provided that delineate all required criteria. |
5 (5%) – 5 (5%)
Paragraphs and sentences follow writing standards for flow, continuity, and clarity.
A clear and comprehensive purpose statement, introduction, and conclusion are provided that delineate all required criteria. |
|
3 (3%) – 3 (3%)
Paragraphs and sentences follow writing standards for flow, continuity, and clarity 60%–79% of the time.
Purpose, introduction, and conclusion of the assignment is vague or off topic. |
0 (0%) – 2 (2%)
Paragraphs and sentences follow writing standards for flow, continuity, and clarity < 60% of the time.
No purpose statement, introduction, or conclusion were provided. |
Written Expression and Formatting—English writing standards:
Correct grammar, mechanics, and proper punctuation |
5 (5%) – 5 (5%)
Uses correct grammar, spelling, and punctuation with no errors. |
|
3 (3%) – 3 (3%)
Contains several (three or four) grammar, spelling, and punctuation errors. |
0 (0%) – 2 (2%)
Contains many (≥ five) grammar, spelling, and punctuation errors that interfere with the reader’s understanding. |
| Written Expression and Formatting – The paper follows correct APA format for title page, headings, font, spacing, margins, indentations, page numbers, running heads, parenthetical/in-text citations, and reference list. |
5 (5%) – 5 (5%)
Uses correct APA format with no errors. |
|
3 (3%) – 3 (3%)
Contains several (three or four) APA format errors. |
0 (0%) – 2 (2%)
Contains many (≥ five) APA format errors. |
| Total Points: 100 |
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Name: NRNP_6540_Week2_Assignment_Rubric
Week 2: Psychosocial CASE SCENARIO
Week 2 Case 1: Dementia
HPI: Ms. Peters is a 70-year-old female who is brought to your office by her son with reports of acute confusion (more than usual) and some agitation and restlessness. She has a known history of dementia, managed with Aricept 10 mg. daily. Her son, Jared, reports that 2 days ago she began to become more confused than usual and very easily agitated. He reports that yesterday, she couldn’t remember where she was in her own home. She had a doctor’s appointment 3 days ago and her HCTZ (hydrochlorothiazide) was increased to 50 mg. due to increased bp’s.
Ms. Peter’s last Mini-Mental State Exam (MMSE) score was 18/30. The assessment was repeated, and the score remained unchanged.
Ms. Peters and her son denies her having any falls or contributing traumas recently. She denies any changes in diet or routine regimens. No reported dysuria, no fever, nausea, or vomiting.
Note: Be sure to review the MMSE and how to interpret results (Mental State Assessment Tests). Make sure you document the patient’s score in your SOAP note document. Also review the Geriatric Depression Assessment (Geriatric Depression Scale [GDS]).
Ms. Peters is a 70-year-old female who is alert but easily distracted, at times, during today’s clinical interview. Her eye contact is fair. Speech is clear and coherent but tangential at times. 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 is alert but disoriented to place and time. She denies any falls, denies any pain. Her son does say she has had some “stumbling” and balance issues but no reported falls.
All other Review of System and Physical Exam findings are negative other than stated.
Vital Signs: 98.1 120/64 HR-72 20
PMH: Hypertension, Diabetes, Osteoporosis, Chronic Allergic Rhinitis
Allergies: Atorvastatin
Medications:
- Multivitamin daily
- Losartan 50mg daily
- HCTZ 50mg daily
- Fish Oil 1 tablet daily
- Glyburide 5mg daily
- Metformin 500mg BID
- Donepezil 10mg daily
- Alendronate 70mg orally once a week
Social History: As stated in Case Study
ROS: As stated in Case study
Diagnostics/Assessments done:
- CXR—no cardiopulmonary findings. WNL
- CT head—diffuse Cerebral Atrophy
- MMSE—Ms. Peters scored 18 out of 30 with primary deficits in orientation, registration, attention and calculation, and recall at a previous visit. At today’s visit, there is no change. The score suggests moderate dementia.
- Hemoglobin A1C7.2%
- Basic Metabolic Panel as shown below
| TEST |
RESULT |
REFERENCE RANGE |
| GLUCOSE |
90 |
65–99 |
| SODIUM |
130 |
135–146 |
| POTASSIUM |
3.4 |
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 |
1.00 |
0.70–1.25 |
| GLOMERULAR FILTRATION RATE (eGFR) |
77 |
>or=60 mL/min/1.73m2 |
Focused SOAP Note Template
Patient Information:
Initials, Age, Sex, Race
S (subjective)
CC (chief complaint): a BRIEF statement identifying why the patient is here, stated in the patient’s own words (for instance “headache,” NOT “bad headache for 3 days”).
HPI (history of present illness): This is the symptom analysis section of your note. Thorough documentation in this section is essential for patient care, coding, and billing analysis. Paint a picture of what is wrong with the patient. Use LOCATES Mnemonic to complete your HPI. You need to start EVERY HPI with age, race, and gender (e.g., 34-year-old AA male). You must include the seven attributes of each principal symptom in paragraph form not a list. If the CC was “headache”, the LOCATES for the HPI might look like the following example:
- Location: Head
- Onset: 3 days ago
- Character: Pounding, pressure around the eyes and temples
- Associated signs and symptoms: Nausea, vomiting, photophobia, phonophobia
- Timing: After being on the computer all day at work
- Exacerbating/relieving factors: Light bothers eyes; Aleve makes it tolerable but not completely better
- Severity: 7/10 pain scale
Current Medications: Include dosage, frequency, length of time used, and reason for use; also include over the counter (OTC) or homeopathic products.
Allergies: Include medication, food, and environmental allergies separately, including a description of what the allergy is (i.e., angioedema, anaphylaxis, etc.). This will help determine a true reaction versus intolerance.
PMHx: Include immunization status (note date of last tetanus for all adults), past major illnesses, and surgeries. Depending on the CC, more info is sometimes needed.
Soc and Substance Hx: Include occupation and major hobbies, family status, tobacco and alcohol use (previous and current use), and any other pertinent data. Always add some health promo question here, such as whether they use seat belts all the time or whether they have working smoke detectors in the house, living environment, text/cell phone use while driving, and support system.
Fam Hx: Illnesses with possible genetic predisposition, contagious, or chronic illnesses. Reason for death of any deceased first-degree relatives should be included. Include parents, grandparents, siblings, and children. Include grandchildren if pertinent.
Surgical Hx: Prior surgical procedures.
Mental Hx: Diagnosis and treatment. Current concerns (anxiety and/or depression). History of self-harm practices and/or suicidal or homicidal ideation.
Violence Hx: Concern or issues about safety (personal, home, community, sexual (current and historical).
Reproductive Hx: Menstrual history (date of LMP), Pregnant (yes or no), Nursing/lactating (yes or no), contraceptive use (method used), types of intercourse (oral, anal, vaginal, other, any sexual concerns).
ROS (review of symptoms): Cover all body systems that may help you include or rule out a differential diagnosis You should list each system as follows:
- General:
- Head:
- EENT (eyes, ears, nose, and throat):
- Etc.:
Note: You should list these in bullet format, and document the systems in order from head to toe.
Example of Complete ROS:
GENERAL: No weight loss, fever, chills, weakness, or fatigue.
HEENT:
- Eyes: No visual loss, blurred vision, double vision or yellow sclerae.
- Ears, Nose, Throat: No hearing loss, sneezing, congestion, runny nose, or sore throat.
SKIN: No rash or itching.
CARDIOVASCULAR: No chest pain, chest pressure or chest discomfort. No palpitations or edema.
RESPIRATORY: No shortness of breath, cough or sputum.
GASTROINTESTINAL: No anorexia, nausea, vomiting or diarrhea. No abdominal pain or blood.
GENITOURINARY: Burning on urination. Last menstrual period (LMP), MM/DD/YYYY.
NEUROLOGICAL: No headache, dizziness, syncope, paralysis, ataxia, numbness or tingling in the extremities. No change in bowel or bladder control.
MUSCULOSKELETAL: No muscle, back pain, joint pain or stiffness.
HEMATOLOGIC: No anemia, bleeding or bruising.
LYMPHATICS: No enlarged nodes. No history of splenectomy.
PSYCHIATRIC: No history of depression or anxiety.
ENDOCRINOLOGIC: No reports of sweating, cold or heat intolerance. No polyuria or polydipsia.
REPRODUCTIVE: Not pregnant and no recent pregnancy. No reports of vaginal or penile discharge. Not sexually active.
ALLERGIES: No history of asthma, hives, eczema or rhinitis.
O (objective)
Physical exam: From head-to-toe, include what you see, hear, and feel when doing your physical exam. You only need to examine the systems that are pertinent to the CC, HPI, and History. Do not use “WNL” or “normal.” You must describe what you see. Always document in head to toe format (i.e., General: Head: EENT: etc.).
Diagnostic results: Include any labs, x-rays, or other diagnostics that are needed to develop the differential diagnoses (support with evidenced and guidelines).
A (assessment)
Differential diagnoses: List a minimum of three differential diagnoses. Your primary or presumptive diagnosis should be at the top of the list. For each diagnosis, provide supportive documentation with evidence-based guidelines.
P (plan)
Includes documentation of diagnostic studies that will be obtained, referrals to other health-care providers, therapeutic interventions, education, disposition of the patient, and any planned follow up visits. Each diagnosis or condition documented in the assessment should be addressed in the plan. The details of the plan should follow an orderly manner.
Also included in this section is the reflection. Reflect on this case, and discuss what you learned, including any “aha” moments or connections you made.
Also include in your reflection, a discussion related to health promotion and disease prevention taking into consideration patient factors (such as, age, ethnic group, etc.), PMH, and other risk factors (e.g., socio-economic, cultural background, etc.).
References
You are required to include 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 to use correct APA 7th edition formatting.
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