Assignment 2: Focused SOAP Note And Patient Case Presentation

For this Assignment, you will document information about a patient that you examined during the last 3 weeks, using the Focused SOAP Note Template provided. You will then use this note to develop and record a case presentation for this patient. Be sure to incorporate any feedback you received on your Week 3 and Week 7 case presentations into this final presentation for the course.

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To Prepare

Be succinct in your presentation, and do not exceed 8 minutes. Specifically address the following for the patient, using your SOAP note as a guide:

• Subjective: What details did the patient provide regarding their chief complaint and symptomology to derive your differential diagnosis? What is the duration and severity of their symptoms? How are their symptoms impacting their functioning in life?
• Objective: What observations did you make during the psychiatric assessment?  Assignment 2: Focused SOAP Note And Patient Case Presentation
• Assessment: Discuss their mental status examination results. What were your differential diagnoses? Provide a minimum of three possible diagnoses and why you chose them. List them from highest priority to lowest priority. What was your primary diagnosis, and why? Describe how your primary diagnosis aligns with DSM-5 diagnostic criteria and supported by the patient’s symptoms.
• Plan: What was your plan for psychotherapy (include one health promotion activity and patient education)? What was your plan for treatment and management, including alternative therapies? Include pharmacologic and nonpharmacologic treatments, alternative therapies, and follow-up parameters, as well as a rationale for this treatment and management plan.
• Reflection notes: What would you do differently with this patient if you could conduct the session over? If you are able to follow up with your patient, explain whether these interventions were successful and why or why not. If you were not able to conduct a follow up, discuss what your next intervention would be. Assignment 2: Focused SOAP Note And Patient Case Presentation

 

Lower Back Pain for the Last Month

Response 1

 

Subjective: .

CC Lower back pain for the last month.

HPI: A 42-year-old Caucasian male experiencing lower back pain, with a quick onset lasting over the last month.  Pain is dull +6/10 and radiates down left leg.  Leaning forward makes it worse while standing straight relieves the pain, denies any other symptoms.

Current Medications: MVI daily, Metformin 500mg BID, Tylenol 1g TID PRN.

Allergies: NKDA

PMHx: Prediabetes – diagnosed 2020

Soc Hx: Pt works night security for local shipping company, HS grad, lives with wife and 1 adult child in single family home.  Retired military with adequate health insurance and coverage, poor dietician stating he’s already got the “sugars”, why stop now?  Last physical is unknown and reports only going to the Dr., when it is needed.  Coaches HS basketball team and active member of his church with strong support system.  No known exposure to pathogens in work or home setting. Lower Back Pain for the Last Month

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Fam Hx: Father – Diagnosed with heart disease/CABG age 45 (living age 80), Brother – Deceased /Myocardial Infarction age 47

ROS:

GENERAL:  Denies tiredness/fatigue/malaise, low grade fever since last night.  Stable weight, no chills or night sweats, no recent infections.

HEENT:  No headaches, wears corrective lens for distance, no visual disturbances.  Denies any ear pain, hearing loss or discharge.  Sense of smell intact, no seasonal allergies, denies any taste changes or problems swallowing.  Good dentition, unknown last dental exam.

SKIN:  Denies any rash, open sores or itching.

CARDIOVASCULAR:  Denies chest pain, SOB, palpitations or any abnormal heart rate.  Strong family history of cardiac problems.

RESPIRATORY:  No SOB, orthopnea, cough, or difficulty breathing

GASTROINTESTINAL:  No GERD, no abdominal pain, no diet change, consistent BMs, no nausea/diarrhea

GENITOURINARY:  No difficulty starting or stopping flow, no dysuria, incontinence, or need for nocturnal micturition.  Monogamous relationship with wife of 20 years, no hx of STD’s.

NEUROLOGICAL:  Denies any issues with gait, no seizures, no recent falls with or without loss of consciousness,.

MUSCULOSKELETAL:  Pain in lumbar region radiating down left leg.

HEMATOLOGIC:  Denies anemia, bleeding or bruising.

LYMPHATICS:  Denies enlarged nodes. No history of splenectomy.

PSYCHIATRIC:  Denies history of depression or anxiety.

ENDOCRINOLOGIC:  Denies reports of sweating, cold or heat intolerance. No polyuria or polydipsia. Lower Back Pain for the Last Month

O.

Physical exam:

Vital signs: T99.9, R18, HR 67, BP 142/78, SPO2 99%RA

General: Clean, well-groomed, no acute distress, Age-appropriate mentation and physical development, well nourished, well developed, Normal affect, good eye contact, standing next to table.

HEENT: Atraumatic, no drainage noted, swallows without difficulty, Face symmetrical, extraocular movements equal, auricles with no lesions or discharge, positive cough and gag reflex, good oral hygiene.

Chest/Lungs: Regular, bilateral and equal unlabored breathing.  Clear breath sounds throughout R&L lobe, last CXR June 2019

Heart/Peripheral Vascular: S1 & S2 noted, no extra heart sounds, NSR, good pulse and capillary refill all extremities, zero edema, color normal for patient

Musculoskeletal: Moves all extremities equally strong and spontaneously, +5/5 muscle strength all 4 extremities.

Neurological: Good sensation in lower extremities.

 

Diagnostic tests

1. Laboratory studies – Pts with acute LBP /not required, however if suspected infection or malignancy ESR and C-Reactive protein (Deyo & Diehl, 2018)
2. Imaging studies – without associated symptoms, use of imaging is not associated with improved outcomes (Chou, Fu, Carrino, & Deyo, 2009).
3. History – Important to consider what factors have brough on the pain.
4. Physical tests. Lower Back Pain for the Last Month
5. Inspection of posterior- check for excessive curvature i.e., kyphosis or scoliosis.
6. Movement – Evaluation of ROM by bending forward/backward/left/right at the waist, Hip ROM,
7. Palpitation – Isolate pain either from spinal region (vertebra) or para-spinal region suggesting paraspinal muscle strain
8. Neuro exam – Straight leg raising test to check for “nerve root irritation or lumbar disk herniation” (Ball, Dains, Flynn, Solomon, & Stewart, 2018).  Tripod sign to check for meningeal irritation. Additionally noting the sensation or lack of in the lower extremities.
9. Reflexes – Check for nerve damage

Differential diagnosis

 

1. Radiculopathy – High suspicion for pain that starts in the lower back and follows down left leg and increased pain while leaning forward, further suspect straight leg test to be positive along with tripod sign.
2. Spinal stenosis – Based upon patients age, and presentation of pain shooting down leg.
3. Vertebral compression fracture – pain that is worse with flexion and focused spinal tenderness, judging from pt’s hx of coaching basketball and if patient were to indorse an acute injury.
4. Lumbar strain / sprain – General diffuse back pain that increases with movement but decreases with rest, uncommon for pain to travel to extremities.
5. Metastatic cancer – by location can be related to multiple symptoms, would need history with associated findings such as weight loss, fatigue, night sweat and no relief with rest to reference. Lower Back Pain for the Last Month

  

Response 2

 

J.M. 15-years-old, Male, Caucasian

S.

CC:  Occasional clicking in one or both knees and a catching sensation under the patella

HPI: 15-year-old Caucasian male comes to the clinic with complaints of a clicking-sound when he moves his knee, along with a catching sensation behind his patella.

Location: Knees (bilaterally)

Onset: 1 month ago

Character: Clicking sound during flexion and extension.

Associated signs and symptoms: Catching sensation behind his patella

Timing: Intermittent occurrence, 3-5 times a day.

Exacerbating/ relieving factors: Clicking is worse after playing baseball and goes away after rest.

Severity: 0/10

Current Medications: Multivitamin, 1 tablet PO qday.

Allergies: Denies allergies to medications, food, or latex.

PMHx: Tdap (2020). Seasonal influenza (2022). Covid-19 (Prizer-2021) – Surgical History – Tonsillectomy (2010).

Soc Hx: Attends Abington Junior High School and has a B-average. Patient plays baseball for the school and in the neighborhood. Denies use of tobacco products, alcohol, or illicit drugs. Patient has a part time job at McDonalds. Patient denies being sexually active.

Fam Hx:

• Mother (age 41) – Diabetes (type II)
• Father (age 40) – Hypothyroidism
• Sister (age 12) – No medical history
• Maternal grandmother (deceased 72 – Breast Cancer) – Hypertension, Diabetes (type II)
• Maternal grandfather (age 75) – Hypertension, Hyperlipidemia
• Paternal grandmother (age 70) – Bilateral knee replacement (2020)
• Paternal grandfather (age 74) – Hypertension, Hypothyroidism, Hyperlipidemia. Lower Back Pain for the Last Month
  

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ROS

GENERAL: Patient denies unintentional weight loss, weakness, or fatigue.

HEENT: Patient denies difficulty with vision. Patient also denies any recent hearing loss, difficulty swallowing, or runny nose.

SKIN:  Patient denies any rashes, redness, or bruising.

CARDIOVASCULAR:  Patient denies chest pain, edema, or shortness of breath upon exertion

RESPIRATORY:  Patient denies difficulty breathing, cough, or congestion.

GASTROINTESTINAL:  Patient reports normal bowel movements, and denies abdominal pain, nausea, and vomiting.

GENITOURINARY:  Patient denies difficulty urinating or

NEUROLOGICAL:  Patient denies headache, dizziness, or numbness in his extremities.

MUSCULOSKELETAL:  Patient endorses an intermittent clicking in both knees, as well as a catching sensation behind his patella.

HEMATOLOGIC:  Denies anemia, bleeding or bruising.

LYMPHATICS:  Denies enlarged nodes.

PSYCHIATRIC:  Patient denies thoughts of harming himself or other people. Patient reports being happy with his life.

ENDOCRINOLOGIC:  Patient denies polyuria, polydipsia, or polyphagia. Patient denies cold intolerance.

ALLERGIES:  Patient denies allergies.

O.

Physical exam:

GENERAL: Patient is dressed appropriately and appears to be practicing proper hygiene. He is attentive during our conversation and responds appropriately.    Lower Back Pain for the Last Month

HEENT: Sclera and conjunctiva normal. Pupils are equal and reactive. No visual drainage from either the nose or the ears. Patient’s throat is pink with no signs of infection.

SKIN:  No bruising or rashes noted. A 3 cm abrasion is present on the patient’s left arm as a result of bumping into a desk at school. Good skin turgor.

CARDIOVASCULAR:  S1 & S2 auscultated with no adventitious heart sounds. No bruit or thrills noted in the carotid arteries. Pulses are +2 in the upper and lower extremities.

RESPIRATORY:  Lung sounds are equal and clear bilaterally. Symmetrical chest and diaphragmatic movement noted.

GASTROINTESTINAL:  Bowel sounds present x 4. Abdomen soft and nontender. Unable to palpate the liver or spleen.

GENITOURINARY:  Genitals intact. No signs of hernia.

NEUROLOGICAL:  Patient is Alert and Oriented x 4, equal strength, movement and sensation in all extremities.

MUSCULOSKELETAL:  Full ROM in all extremities. “Clicking-sound” noted when performing flexion and extension in the left leg.

HEMATOLOGIC:  No visible signs of bruising. Mucus membranes are pink and moist.

LYMPHATICS:  No swollen lymph nodes detected.

Diagnostic results: Knee X-ray (AP and Lateral)

A.

• Damaged Cartilage – The catching sensation when moving the knee may be indicative of cartilage damage in the knee (Keeling, 2011).
• Iliotibial Band Syndrome – May cause intermittent knee crepitus and is seen often in athletes due to repeated use and impact on the lower extremities (Geisler, 2021).
• Patellar Tracking Disorder – If the patient’s patella is not tracking properly it may cause instability in the patellofemoral joint which would account for the catching sensation the patient is experiencing (Xue, et al., 2020)
• Osteoarthritis of the Knee – Unlikely in a patient of this age, but something that should be checked nonetheless due to the risk of further deterioration and loss of mobility.
• Air bubbles in Synovial Space – Normal occurrence which would account for the clicking sound but not the catching sensation  .  Lower Back Pain for the Last Month

In determining the causes of the knee pain, what additional history do you need?

• History of trauma, prior surgical history, and lifestyle assessment (activity level).

What categories can you use to differentiate knee pain?

• Frequency of the knee pain, characteristics of the knee pain, and severity.

What are your specific differential diagnoses for knee pain?

• Cartilage damage, torn ligament, osteoarthritis.  

What physical examination will you perform?

• Visual inspect the patient’s knees for any signs of swelling

What anatomic structures are you assessing as part of the physical examination?

• Anterior Cruciate Ligament, Posterior Cruciate Ligament, Medial Meniscus, Lateral Meniscus, and Patella

What special maneuvers will you perform?

• Patella, McMurray Test, Drawer Test, Lachman Test. Lower Back Pain for the Last Month

 

Please Reply to the following 2 Discussion posts:

 

Requirement

 

APA format with intext citation

Word count minimum of 150 words per post

References at least one high-level scholarly reference per post within the last 5 years in APA format.

Plagiarism free.

Turnitin receipt.

 

DISCUSSION POST # 1 Elaine

 

There are two types of research methods used in nursing: qualitative and quantitative. Quantitative research involves a systematic approach to data collection and seeks to “minimize bias and maximize validity” (Polit & Beck, 2018, p.41). The goal is to study a particular element, obtain empirical evidence, usually in the form of numerical measurements, and seek to make a generalization of the intervention beyond the study participants to a population as a whole. The quantitative data includes examinations, numerical measurements, and questionnaires, and is objective in nature (Dodd, 2008). An example of a qualitative research study is whether incorporating postpartum depression screening during well-child visits by a pediatrician would increase the detection and treatment of postpartum depression. This study can provide numerical measurements and be generalized to the greater population beyond just the study sample. Nursing homework help

Qualitative research studies are used to examine specific experiences as lived through the eyes of a certain patient or population. Qualitative data is often narrative and involves biased and subjective information with the goal of understanding the human experience (Polit & Beck, 2018). The data is often collected using focus groups, interviews, or observation (Dodd, 2008). Qualitative researchers believe that there is more to experiences than what can be captured quantitatively.  Results are numerical only in study population descriptions, i.e. percentage of males and females in the study, but the specific study results are often narrative and include word tables and descriptions (Polit & Beck, 2018). A qualitative study I would be interested in is women’s opinions on the understanding of hormone replacement therapy and their views of their providers’ understanding, teaching, and readiness to prescribe. Another one would be women’s attitude and understanding of hormone replacement therapy using testosterone. This is a similar area to my PICOT and also something I have struggled to find answers for as a patient as well. It would be interesting to see what other women’s views and experiences are as well. Nursing homework help

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DISCUSSION POST # 2 Ashlesha

Nursing research is inevitable for advancing the profession and knowledge because it affects patient outcomes. Nursing research is vital to practice evidence-based practice to validate the evidence-based practice outcome.

First, it’s essential to understand the difference between qualitative and quantitative research for research. According to Chuck Miller (May 18, 2020), Qualitative research is primarily exploratory and helps a researcher better understand motivations, needs, processes, and rationale for behaviors (among other things). It provides deep insights into a situation and supports form ideas or hypotheses for potential quantitative research.

Quantitative research, like online surveys, tends to be more numbers-focused and can help to assess hypotheses from qualitative research. Adding a quantitative approach to qualitative research can provide a more holistic (and quantifiable) view of the subject matter you are researching (Chuck Miller, 2020). The goal of both quantitative and qualitative researchers is to discover the truth about the phenomena in which they are interested (Polit & Beck, 2018).

In the emergency department, we encounter many terminally ill patients with family members who are their primary caretakers. Regarding qualitative research, I would be interested in the following research question: How do family members of terminally-ill patients experience placing their terminally-ill family members on hospice care?  Regarding quantitative research and the emergency department, I would be interested in the following research question: What relationship is between patient satisfaction scores and emergency department wait times?  Nursing homework help

 

 

Quantitative and Qualitative Studies

Qualitative research offers a different set of processes to explore phenomena of interest to nursing, compared to quantitative processes. Both are necessary to advance the profession of nursing. To learn why, discuss how the steps in the research process are different between quantitative and qualitative studies. You should include the following:

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• Select 2 key differences between qualitative and quantitative research and describe. Use examples to illustrate. Quantitative and Qualitative Studies
• Are there terms used in quantitative processes that are not used in qualitative processes, and vice versa?
• How is qualitative research used in evidence-based practice?
• Select a topic of clinical interest to you. It should be very broad in nature (e.g., cancer pain, psychiatric inpatient anxiety, etc.). Conduct a literature search to select 3 research reports: one using a quantitative approach, one using a qualitative approach, and one using a mixed methods approach to study the selected topic. In your own words, summarize the differences. Describe how you would determine if these studies could be applied to your clinical practice.
• Attach the following 3 documents as PDFs to your initial post: mixed method report, quantitative report, and qualitative report.  Quantitative and Qualitative Studies