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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 episodic/focused note
template provided in the Week 5 resources. 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.
Assignment 1: Case Study Assignment: Assessing Neurological Symptoms
Imagine not being able to form new memories. This is the reality patients with anterograde
amnesia face. Although this form of amnesia is rare, it can result from severe brain trauma.
Anterograde amnesia demonstrates just how impactful brain disorders can be to a patient’s
quality of living. Accurately assessing neurological symptoms is a complex process that involves
the analysis of many factors.
In this Case Study Assignment, you will consider case studies that describe abnormal findings in
patients seen in a clinical setting.
Week 1 Assignment- Case Study- Assessing Neurological Symptoms
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. You will be making up the information that is missing to
complete this soap note.
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 episodic/focused note template provided
in the Week 5 resources. 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. By Day 6 of Week 9.
Case Study 3: Facial Droop
22 year old African American female looks in the mirror and notices the left side of her mouth is
slanted when she smiles. She notes she has had some headache off and on a few days. Her taste
has decreased as well when she started brushing her teeth.
Using the
Episodic/Focused SOAP
Template:
· Create documentation
or an episodic/focused
note in SOAP format
about the patient in the
case study to which you
were assigned.
Points Range:45 (45.00%) 50 (50.00%)
The response clearly,
accurately, and thoroughly
follows the SOAP format to
document the patient in
the assigned case study.
The response thoroughly
and accurately provides
detailed evidence from the
literature to support
diagnostic tests that would
be appropriate for the
patient in the assigned case
study.
Points Range:39 (39.00%) 44 (44.00%)
The response accurately
follows the SOAP format
to document the patient in
the assigned case study.
The response accurately
provides detailed evidence
from the literature to
support diagnostic tests
that would be appropriate
for the patient in the
assigned case study.
Points R
38 (38.00
The resp
SOAP fo
the patie
case stu
vaguene
The resp
evidence
to suppo
that wou
for the p
assigned
some va
inaccura
selected
· List five different
possible conditions for
the patient’s differential
diagnosis, and justify
why you selected each.
Points Range:30 (30.00%) 35 (35.00%)
The response lists five
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
five conditions selected.
Points Range:24 (24.00%) 29 (29.00%)
The response lists four to
five different possible
conditions for a
differential diagnosis of
the patient in the assigned
case study and provides
an accurate justification
for each of the five
conditions selected.
Points R
23 (23.00
The resp
four pos
a differe
the patie
case stu
vaguene
inaccura
and/or j
each.
Written Expression and
Formatting – Paragraph
Development and
Organization:
Paragraphs make clear
points that support welldeveloped ideas, flow
Points Range:5 (5.00%) 5 (5.00%)
Paragraphs and sentences
follow writing standards for
flow, continuity, and clarity.
A clear and comprehensive
Points Range:4 (4.00%) 4 (4.00%)
Paragraphs and sentences
follow writing standards
for flow, continuity, and
clarity 80% of the time.
Points R
3 (3.00%
Paragrap
follow w
flow, con
60%–79%
· Provide evidence from
the literature to support
diagnostic tests that
would be appropriate for
your case.
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.
purpose statement,
introduction, and
conclusion are provided
that delineate all required
criteria.
Purpose, introduction, and
conclusion of the
assignment are stated, yet
are brief and not
descriptive.
Purpose
conclusi
assignm
off topic
Written Expression and
Formatting – English
writing standards:
Correct grammar,
mechanics, and proper
punctuation
Points Range:5 (5.00%) 5 (5.00%)
Uses correct grammar,
spelling, and punctuation
with no errors.
Points Range:4 (4.00%) 4 (4.00%)
Contains a few (1 or 2)
grammar, spelling, and
punctuation errors.
Points R
3 (3.00%
Contains
gramma
punctua
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.
Points Range:5 (5.00%) 5 (5.00%)
Uses correct APA format
with no errors.
Points Range:4 (4.00%) 4 (4.00%)
Contains a few (1 or 2)
APA format errors.
Points R
3 (3.00%
Contains
APA form
Name:NURS_6512_Week_9_Assignment1_Rubric
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: Denies weight loss, fever, chills, weakness or fatigue.
HEENT: Eyes: Denies visual loss, blurred vision, double vision or yellow sclerae. Ears, Nose,
Throat: Denies hearing loss, sneezing, congestion, runny nose or sore throat.
SKIN: Denies rash or itching.
CARDIOVASCULAR: Denies chest pain, chest pressure or chest discomfort. No palpitations or
edema.
RESPIRATORY: Denies shortness of breath, cough or sputum.
GASTROINTESTINAL: Denies anorexia, nausea, vomiting or diarrhea. No abdominal pain or
blood.
GENITOURINARY: Burning on urination. Pregnancy. Last menstrual period, MM/DD/YYYY.
NEUROLOGICAL: Denies headache, dizziness, syncope, paralysis, ataxia, numbness or
tingling in the extremities. No change in bowel or bladder control.
MUSCULOSKELETAL: Denies muscle, back pain, joint pain or stiffness.
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.
ALLERGIES: Denies history of asthma, hives, eczema or rhinitis.
© 2021 Walden University, LLC
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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 3 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.
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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