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Instructions: To create a focused/episodic note, you must make up information for all aspects. I strongly encourage you to review previous feedback. In some cases, there are notes still being submitted that do no incorporate feedback. For example, your HPI should capture all aspects of the LOCATES mnemonic. Medical conditions listed for the past medical history should reflect the year of the diagnosis – not age. Calculate the year of the diagnosis. How is the condition managed? There are four categories for allergies – food, drugs, environmental, and latex. Seasonal is not a fifth category. It should be listed under environmental. Personal/Social, Sexual/Reproductive, and Health Maintenance should be robust and written in narrative format. With regard to the case study you were assigned: Review this week’s Learning Resources, and consider the insights they provide about the case study.Consider what history would be necessary to collect from the patient in the case study you were assigned.Consider what physical exams and diagnostic tests would be appropriate to gather more information about the patient’s condition. How would the results be used to make a diagnosis?Identify at least five possible conditions that may be considered in a differential diagnosis for the patient. If your assignment is focused, then you are expected to select systems pertinent to the chief complaint. THE CASE STUDY ASSIGNMENT Use the Episodic/Focused SOAP Template and create an episodic/focused note about the patient in the case study to which you were assigned using the attached episodic/focused note template. Provide evidence from the literature to support diagnostic tests that would be appropriate for each case. List five different possible conditions for the patient’s differential diagnosis, and justify why you selected each using current both classroom and outside resources. The Case study: A 48 year old male with a history of diabetes mellitus type 2 complains of not being able to feel his toes in the left foot. He also complains of numbness in the heel of the right foot and a tingling sensation. Required Readings Ball, J. W., Dains, J. E., Flynn, J. A., Solomon, B. S., & Stewart, R. W. (2023). Seidel’s guide to physical examination: An interprofessional approach (10th ed.). St. Louis, MO: Elsevier Mosby.Chapter 7, “Mental Status” This chapter revolves around the mental status evaluation of an individual’s overall cognitive state. The chapter includes a list of mental abnormalities and their symptoms.Chapter 23, “Neurologic System” The authors of this chapter explore the anatomy and physiology of the neurologic system. The authors also describe neurological examinations and potential findings. Dains, J. E., Baumann, L. C., & Scheibel, P. (2019). Advanced health assessment and clinical diagnosis in primary care (6th ed.). St. Louis, MO: Elsevier Mosby. Credit Line: Advanced Health Assessment and Clinical Diagnosis in Primary Care, 6th Edition by Dains, J.E., Baumann, L. C., & Scheibel, P. Copyright 2019 by Mosby. Reprinted by permission of Mosby via the Copyright Clearance Center.Sullivan, D. D. (2019). Guide to clinical documentation (3rd ed.). Philadelphia, PA: F. A. Davis.Chapter 2, “The Comprehensive History and Physical Exam” (“Cranial Nerves and Their Function” and “Grading Reflexes”) (Previously read in Weeks 1, 2, 3, and 5) O’Caoimh, R., & Molloy, D. W. (2019). Comparing the diagnostic accuracy of two cognitive screening instruments in different dementia subtypes and clinical depression.Links to an external site. Diagnostics, 9(3), 93. https://doi.org/10.3390/diagnostics9030093 Shadow Health Support and Orientation Resources Use the following resources to guide you through your Shadow Health orientation as well as other support resources: Shadow Health. (2021). Welcome to your introduction to Shadow Health.Links to an external site. https://link.shadowhealth.com/Student-Orientation-…Shadow Health. (n.d.). Shadow Health help desk.Links to an external site.Retrieved from https://support.shadowhealth.com/hc/en-usShadow Health. (2021). Walden University quick start guide: NURS 6512 NP students. Download Walden University quick start guide: NURS 6512 NP students. https://link.shadowhealth.com/Walden-NURS-6512-Stu…Document: DCE (Shadow Health) Documentation Template for Comprehensive (Head-to-Toe) Physical Assessment (Word document)Download DCE (Shadow Health) Documentation Template for Comprehensive (Head-to-Toe) Physical Assessment (Word document) Use this template to complete your Assignment 3 for this week. Required Media Neurologic System – Week 9 (16m) Online media for Seidel’s Guide to Physical Examination It is highly recommended that you access and view the resources included with the course text, Seidel’s Guide to Physical Examination. Focus on the videos and animations in Chapters 7 and 23 that relate to the assessment of cognition and the neurologic system. Refer to the Week 4 Learning Resources area for access instructions on https://evolve.elsevier.com/Links to an external site. Optional Resources LeBlond, R. F., Brown, D. D., & DeGowin, R. L. (2020). DeGowin’s diagnostic examination (11th ed.). New York, NY: McGraw Hill Medical.Chapter 14, “The Neurologic Examination” This chapter provides an overview of the nervous system. The authors also explain the basics of neurological exams.Chapter 15, “Mental Status, Psychiatric, and Social Evaluations” In this chapter, the authors provide a list of common psychiatric syndromes. The authors also explain the mental, psychiatric, and social evaluation process.Kim, H., Lee, S., Ku, B. D., Ham, S. G., & Park, W. (2019). Associated factors for cognitive impairment in the rural highly elderly.Links to an external site. Brain and Behavior, 9(5), e01203. https://doi.org/10.1002/brb3.1203 Lee, K., Puga, F., Pickering, C. E., Masoud, S. S., & White, C. L. (2019). Transitioning into the caregiver role following a diagnosis of Alzheimer’s disease or related dementia: A scoping review.Links to an external site. International Journal of Nursing Studies, 96, 119–131. https://doi.org/10.1016/j.ijnurstu.2019.02.007
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Episodic/Focused SOAP Note Template
Patient Information:
Initials, Age, Sex, Race
S.
CC (chief complaint) a BRIEF statement identifying why the patient is here – in the patient’s
own words – for instance “headache”, NOT “bad headache for 3 days”.
HPI: 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 OTC or homeopathic products.
Allergies: include medication, food, and environmental allergies separately (a description of
what the allergy is ie angioedema, anaphylaxis, etc. This will help determine a true reaction vs
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 Hx: include occupation and major hobbies, family status, tobacco & alcohol use (previous
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and current use), 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.
ROS: 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: etc. You should list these in bullet
format and document the systems in order from head to toe.
Example of Complete ROS:
GENERAL:
HEENT
SKIN:
CARDIOVASCULAR:
RESPIRATORY: .
GASTROINTESTINAL
GENITOURINARY:
NEUROLOGICAL:
MUSCULOSKELETAL:
HEMATOLOGIC:
LYMPHATICS
PSYCHIATRIC:
ENDOCRINOLOGIC:
ALLERGIES: Denies history of asthma, hives, eczema or rhinitis.
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O.
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.
Differential Diagnoses (list a minimum of 5 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. For a holistic approach and treatment, include all
old diagnoses and indicate if they are managed or not (these are not part of the 5 DDx).
P.
This section is not required for the assignments in this course (NURS 6512) but will be required
for future courses.
References
You are required to include at least three evidence based peer-reviewed journal articles or
evidenced based guidelines which relates to this case to support your diagnostics and
differentials diagnoses. Be sure to use correct APA 7th edition formatting.
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