For this assignment, you are to complete a clinical case – narrated PowerPoint report that will follow the SOAP note example provided below. The case report will be based on the clinical case scenario list below.   

You are to approach this clinical scenario as if it is a real patient in the clinical setting. 

Instructions:

Step 1 – Read the assigned clinical scenario and using your clinical reasoning skills, decide on the diagnoses. This step informs your next steps.

Step 2 – Document the given information in the case scenario under the appropriate sections, headings, and subheadings of the SOAP note.

Step 3 – Document all the classic symptoms typically associated with the diagnoses in Step 1. This information may NOT be given in the scenario; you are to obtain this information from your textbooks. Include APA citations.

Example of Steps 1 – 3:

You decided on Angina after reading the clinical case scenario (Step 1)

Review of Symptoms (list of classic symptoms):

CV: sweating, squeezing, pressure, heaviness, tightening, burning across the chest starting behind the breastbone

GI: indigestion, heartburn, nausea, cramping

Pain: pain to the neck, jaw, arms, shoulders, throat, back, and teeth

Resp: shortness of breath

Musculo: weakness

Step 4 – Document the abnormal physical exam findings typically associated with the acute and chronic diagnoses decided on in Step 1. Again, this information may NOT be given. Cull this information from the textbooks. Include APA citations.

Example of Step 4:

You determined the patient has Angina in Step 1

Physical Examination (list of classic exam findings):

CV: RRR, murmur grade 1/4

Resp: diminished breath sounds left lower lobe

Step 5 – Document the diagnoses in the appropriate sections, including the ICD-10 codes, from Step 1. Include three differential diagnoses. Define each diagnosis and support each differential diagnosis with pertinent positives and negatives and what makes these choices plausible. This information may come from your textbooks. Remember to cite using APA.

Step 6 – Develop a treatment plan for the diagnoses. Only use National Clinical Guidelines to develop your treatment plans. This information will not come from your textbooks. Use your research skills to locate appropriate guidelines. The treatment plan must address the following:

a) Medications (include the dosage in mg/kg, frequency, route, and the number of days)

b) Laboratory tests ordered (include why ordered and what the results of the test may indicate)

c) Diagnostic tests ordered (include why ordered and what the results of the test may indicate)

d) Vaccines administered this visit & vaccine administration forms given,

e) Non-pharmacological treatments

f) Patient/Family education including preventive care

g) Anticipatory guidance for the visit (be sure to include exactly what you discussed during the visit; review Bright Futures website for this section)

h) Follow-up appointment with a detailed plan of f/u

As you develop your narrated PowerPoint, be sure to address the criteria discussed in the video above and the instructions listed below:

FOLLOW THE TEMPLATE BELOW for the Clinical Case Report – SOAP PowerPoint Assignment:

DO NOT INCLUDE THESE INSTRUCTIONS IN THE POWERPOINT. POINTS WILL BE DEDUCTED. REFER TO THE EXAMPLE CASE REPORT FOR GUIDANCE.

SUBJECTIVE (S): Describes what the patient reports about their condition.

For INITIAL visits gather the info below from the clinical scenario and the textbook. DO NOT COPY AND PASTE THE SCENARIO; EXTRACT THE RELEVANT INFORMATION.

Historian (required; unless the patient is 16 y/o and older): document name and relationship of guardian

Patient’s Initials + CC (Identification and Chief Complaint): E.g. 6-year-old female here for evaluation of a palmar rash

HPI (History of Present Illness): Remember OLD CAARTS (onset, location, duration, character, aggravating/alleviating factors, radiation, temporal association, severity) written in paragraph form

PMH (Past Medical History): List any past or present medical conditions, surgeries, or other medical interventions the patient has had. Specify what year they took place

MEDs: List prescription medications the patient is taking. Include dosage and frequency if known. Inquire and document any over-the-counter, herbal, or traditional remedies.

Allergies: List any allergies the patient has and indicate the reaction. e.g. Medications (tetracycline-> shortness of breath), foods, tape, iodine->rash

FH (Family History): List relevant health history of immediate family: grandparents, parents, siblings, or children. e.g. Inquire about any cardiovascular disease, HTN, DM, cancer, or any lung, liver, renal disease, etc…

SHx (Social history): document parent’s work (current), educational level, living situation (renting, homeless, owner), substance use/abuse (alcohol, tobacco, marijuana, illicit drugs), firearms in-home, relationship status (married, single, divorced, widowed), number of children in the home (in SF or abroad), how recently pt immigrated to the US and from what country of origin (if applicable), the gender of sexual partners, # of partners in last 6 mo, vaginal/anal/oral, protected/unprotected.

Patient Profile: Activities of Daily Living (age-appropriate): (include feeding, sleeping, bathing, dressing, chores, etc.), Changes in daycare/school/after-school care, Sports/physical activity, and Developmental History: (provide a history of development over the child’s lifespan. If a child is 1y/o or younger, provide birth history also)

HRB (Health-related behaviors):

ROS (Review of Systems): Asking about problems by organ system systematically from head-to-toe. Included classic associated symptoms (this includes pertinent negatives and positives).

OBJECTIVE: Physical findings you observe or find on the exam.

1. Age, gender, general appearance

2. Vitals – HR, BP, RR, Temp, BMI, Height & Percentile; Weight & Percentile, Include the Growth Chart

3. Physical Exam: note pertinent positives and negatives (refer to the textbook for classic findings related to present complaint and the diagnosis you believe the patient has)

4. Lab Section – what results do you have?

5. Studies/Radiology/Pap Results Section – what results do you have?

RISK FACTORS: List risk factors for the acute and chronic conditions

ASSESSMENT: What do you think is going on based on the clinical case scenario? This is based on the case. You are to list the acute diagnosis and three differential diagnoses, in order of what is likely, possible, and unlikely (include supporting information that helped you to arrive at these differentials). You must include the ICD-10 codes, the definition for the acute and differential diagnoses, and the pertinent positives and negatives of each diagnosis.

You are to also list any chronic conditions with the ICD-10 codes.

NATIONAL CLINICAL GUIDELINES: List the guidelines you will use to guide your treatment and management plan

TREATMENT & MANAGEMENT PLAN: Number problems (E.g. 1. HTN, 2. DM, 3. Knee sprain), use bullet points, and include A – F below for each diagnosis and G – H after you’ve addressed all conditions.

Example:

1. HTN

a) Vaccines administered this visit & vaccine administration forms given,

b) Medication-include dosage amounts and mg/kg for drug and number of days,

c) Laboratory tests ordered

d) Diagnostic tests ordered

e) Non-pharmaceutical treatments

f) Patient/Family education including preventive care

2. HLD

a) Vaccines administered this visit & vaccine administration forms given,

b) Medication-include dosage amounts and mg/kg for drug and number of days,

c) Laboratory tests ordered

d) Diagnostic tests ordered

e) Non-pharmaceutical treatments

f) Patient/Family education including preventive care

Also discussed:

g) Anticipatory guidance for next well-child visit (be sure to include exactly what you discussed during the visit; review Bright Futures website for this section)

Return to the clinic:

h) Follow-up appointment with a detailed plan for f/u and any referrals

 
CLINICAL CASE SCENARIO

A 17-year-old student presents to your clinic with several days of fever, sore throat, malaise, and a new rash that developed today. She first started feeling ill ten (10) days ago with general malaise, headache, and nausea. Four days ago, she developed a temperature of 103°F that has persisted. She has a worsening sore throat and difficulty swallowing solid foods, and she is drinking well. She denies emesis, diarrhea, or contact with a sick person. She takes an oral contraceptive daily and took two doses of amoxicillin yesterday (leftover from a prior illness). On examination, the patient is well developed with a diffuse morbilliform rash; she appears tired but in no distress. Her temperature is 102.2°F, BP 130/80, HR 105, RR 20. She is 64 inches tall and weighs 120 pounds. She has mild supraorbital edema, bilaterally enlarged tonsils coated with gray exudate, a few petechiae on the palate and uvula, bilateral posterior cervical lymphadenopathy, and a spleen that is palpable 3 cm below the costal margin. Laboratory data include a white blood cell (WBC) count of 17,000 cells/mm3 with 50% lymphocytes, 15% atypical lymphocytes, and a platelet count of 100,000/mm3.

Diagnosis – Infectious Mononucleosis

  Throughout the RN-to-BSN program, students are required to participate in scholarly activities outside of clinical practice or professional practice. Examples of scholarly activities include attending conferences, seminars, journal club, grand rounds, morbidity and mortality meetings, interdisciplinary committees, quality improvement committees, and any other opportunities available at your site, within your community, or nationally.

You are required to post at least one documented scholarly activity by the end of this course. In addition to this submission, you are required to be involved and contribute to interdisciplinary initiatives on a regular basis.

Submit, by way of this assignment, a summary report of the scholarly activity, including who, what, where, when, and any relevant take-home points. Include the appropriate program competencies associated with the scholarly activity as well as future professional goals related to this activity. You may use the “Scholarly Activity Summary” resource to help guide this assignment.

This document describes the scholarly activity elements that should be included in a five paragraph summary. You may use this resource to help guide the preparation of the Scholarly Activities assignment, due in Topic 10. 

Overview 

This section consists of a single paragraph that succinctly describes the scholarly activity that you attended/participated in, the target market for the activity, and the benefit of the activity to you. 

Problem 

This section consists of either a short narrative or a list of bullet points that concisely identifies the problems the scholarly activity is designed to solve. Educate: What is the current state of the activity topic? Explain why this is a problem, and for whom is it a problem? Inspire: What could a nurse achieve by participating in the scholarly activity? Use declarative sentences with simple words to communicate each point. Less is more. 

Solution 

This section consists of either a short paragraph or a list of bullet points that concisely describes the solution to a proposed practice problem Work Overload in Healthcare System that the scholarly activity addressed and how it addresses the problem  outlined in the previous section. 

Opportunity 

This section consists of short paragraphs that define the opportunity that the scholarly activity is designed to capture. It is important to cover the objectives and goals that were met. How will attending/participating in this scholarly activity help you grow as a nurse? 

Program Competencies Addressed

This section consists of a list of program competencies that were addressed in this scholarly activity.

Please use the list from the ISP.

“ISP”

A. Domains and Competencies

How does this Individual Success Plan support the Program Domains and Competencies?

Domain 1: Professional Role 

Graduates of Grand Canyon University’s RN-BSN program will be able to incorporate professional values to advance the nursing profession through leadership skills, political involvement, and life-long learning.

Competencies:

1.1: Exemplify professionalism in diverse health care settings.

1.2: Manage patient care within the changing environment of the health care system.

1.3: Exercise professional nursing leadership and management roles in the promotion of patient safety and quality care.

1.4: Participate in health care policy development to influence nursing practice and health care.

1.5: Advocate for autonomy and social justice for individuals and diverse populations. 

Domain 2: Theoretical Foundations of Nursing Practice

Graduates of Grand Canyon University’s RN-BSN program will have acquired a body of nursing knowledge built on a theoretical foundation of liberal arts, science, and nursing concepts that will guide professional practice.

Competencies:

2.1: Incorporate liberal arts and science studies into nursing knowledge.

2.2: Comprehend nursing concepts and health theories.

2.3: Understand and value the processes of critical thinking, ethical reasoning, and decision making.

Domain 3: Nursing Practice

Graduates of Grand Canyon University’s RN-BSN program will be able to utilize the nursing process to provide safe quality care based on nursing best practices.

Competencies:

3.1: Utilize the nursing process to provide safe and effective care for patients across the lifespan

3.2: Implement patient care decisions based on evidence-based practice.

3.3: Provide individualized education to diverse patient populations in a variety of health care settings.

3.4: Demonstrate professional standards of practice.

Domain 4: Communication/Informatics

Graduates of Grand Canyon University’s RN-BSN program will be able to manage information and technology to provide safe quality care in a variety of settings. In addition, graduates will be able to communicate therapeutically and professionally to produce positive working relationships with patients and health care team members.

Competencies:

4.1: Utilize patient care technology and information management systems.

4.2: Communicate therapeutically with patients.

4.3: Promote interprofessional collaborative communication with health care teams to provide safe and effective care.

Domain 5: Holistic Patient Care

Graduates of Grand Canyon University’s RN-BSN program will be able to provide holistic individualized care that is sensitive to cultural and spiritual aspects of the human experience.

Competencies:

5.1: Understand the human experience across the health-illness continuum.

5.2: Assess for the spiritual needs and provide appropriate interventions for individuals, families, and groups.

5.3: Provide culturally sensitive care.

5.4: Preserve the integrity and human dignity in the care of all patients.

 

In the first paragraph of this chapter, the quote from Harold Coffin (1905-1981) stated: “A consumer is a shopper who is sore about something.” In essence, Mr. Coffin suggests that a marketer’s job is to tap into a problem, or create a “problem,” that can only be “solved” by the consumer’s purchase of a particular product. Based on this concept, describe how consumer purchase decisions actually serve to resolve an unmet want or need? In replies to peers, provide real-world examples from your own life to illustrate the point.

• Legal issues, ethical considerations and risk management (insurance) – In your opinion, what is the relationship among these topics as they relate to NP’s?
• Define/describe what each of these are.
• Describe how each of these are interrelated.
• Provide an example of how ethics is interrelated into the legal issues of malpractice.
• Provide a journal summary to support your ideas.
• Please use ANA Code of Ethical Standards to guide the ethics discussion.

Parameters:

APA7, references, and 400 words