course materials

1. MSN5600L Acute Diseases Discussion
MSN5600L Acute Diseases DiscussionMSN5600L Acute Diseases DiscussionPick any Acute
Disease from Weeks 1-5 (see syllabus)Must use the sample template for your soap note,
keep this template for when you start clinicals.Late Assignment PolicyAssignments turned
in late will have 1 point taken off for every day assignment is late, after 7 days assignment
will get grade of 0. No exceptionsFollow the MRU Soap Note Rubric as a guideUse APA
format and must include minimum of 2 Scholarly Citations.Soap notes will be uploaded to
Moodle and put through TURN-It-In (anti-Plagiarism program)Turn it in Score must be less
than 50% or will not be accepted for credit, must be your own work and in your own words.
You can resubmit, Final submission will be accepted if less than 50%. Copy paste from
websites or textbooks will not be accepted or tolerated. Please see College Handbook with
reference to Academic Misconduct Statement.The use of tempates is ok with regards of
Turn it in, but the Patient History, CC, HPI, The Assessment and Plan should be of your own
work and individualized to your made up patient.ORDER NOW FOR CUSTOMIZED,
PLAGIARISM-FREE PAPERSSince at all of the white-ups that you hand in are uniform, this
represents what MUST be included in every write-up. 1) Identifying Data (___5pts): The
opening list of the note. It contains age, sex, race, marital status, etc. The patient complaint
should be given in quotes. If the patient has more than one complaint, each complaint
should be listed separately (1, 2, etc.) and each addressed in the subjective and under the
appropriate number. 2) Subjective Data (___30pts.): This is the historical part of the note. It
contains the following: a) Symptom analysis/HPI(Location, quality , quantity or severity,
timing, setting, factors that make it better or worse, and associate manifestations.(10pts). b)
Review of systems of associated systems, reporting all pertinent positives and negatives
(10pts). c) Any PMH, family hx, social hx, allergies, medications related to the
complaint/problem (10pts). If more than one chief complaint, each should be written u in
this manner. 3) Objective Data(__25pt.): Vital signs need to be present. Height and Weight
should be included where appropriate. a) b) c) MSN5600L Acute Diseases
DiscussionAppropriate systems are examined, listed in the note and consistent with those
identified in 2b.(10pts). Pertinent positives and negatives must be documented for each
relevant system. Any abnormalities must be fully described. Measure and record sizes of
things (likes moles, scars). Avoid using “ok”, “clear”, “within normal limits”, positive/
negative, and normal/abnormal to describe things. (5pts). 4) Assessment (___10pts.):
Diagnoses should be clearly listed and worded appropriately. 5) Plan (___15pts.): Be sure to
include any teaching, health maintenance and counseling along with the pharmacological

2. and non-pharmacological measures. If you have more than one diagnosis, it is helpful to
have this section divided into separate numbered sections. 6) Subjective/ Objective,
Assessment and Management and Consistent (___10pts.): Does the note the appropriate
differential diagnosis process? Is there evidence that you know what systems and what
symptoms go with which complaints? The assessment/diagnoses should be consistent with
the subjective section and then the assessment and plan. The management should be
consistent with the assessment/ diagnoses identified. 7) Clarity of the Write-up(___5pts.): Is
it literate, organized and complete? Comments: Total Score: ____________ Instructor:
__________________________________ Guidelines for Focused SOAP Notes · Label each section of the
SOAP note (each body part and system). · Do not use unnecessary words or complete
sentences. · Use Standard Abbreviations S: SUBJECTIVE DATA (information the
patient/caregiver tells you). Chief Complaint (CC): a statement describing the patient’s
symptoms, problems, condition, diagnosis, physician-recommended return(s) for this
patient visit. The patient’s own words should be in quotes. History of present illness (HPI): a
chronological description of the development of the patient’s chief complaint from the first
symptom or from the previous encounter to the present. Include the eight variables (Onset,
Location, Duration, Characteristics, Aggravating Factors, Relieving Factors, Treatment,
Severity-OLDCARTS), oMSN5600L Acute Diseases Discussionr an update on health status
since the last patient encounter. Past Medical History (PMH): Update current medications,
allergies, prior illnesses and injuries, operations and hospitalizations allergies, age-
appropriate immunization status. Family History (FH): Update significant medical
information about the patient’s family (parents, siblings, and children). Include specific
diseases related to problems identified in CC, HPI or ROS. Social History(SH): An age-
appropriate review of significant activities that may include information such as marital
status, living arrangements, occupation, history of use of drugs, alcohol or tobacco, extent of
education and sexual history. Review of Systems (ROS). There are 14 systems for review.
List positive findings and pertinent negatives in systems directly related to the systems
identified in the CC and symptoms which have occurred since last visit; (1) constitutional
symptoms (e.g., fever, weight loss), (2) eyes, (3) ears, nose, mouth and throat, (4)
cardiovascular, (5) respiratory, (6) gastrointestinal, (7) genitourinary, (8) musculoskeletal,
(9}.integument (skin and/or breast), (10) neurological, (11) psychiatric, (12) endocrine,
(13) hematological/lymphatic, {14) allergic/immunologic. The ROS should mirror the PE
findings section. 0: OBJECTIVE DATA (information you observe, assessment findings, lab
results). Sufficient physical exam should be performed to evaluate areas suggested by the
history and patient’s progress since last visit. Document specific abnormal and relevant
negative findings. Abnormal or unexpected findings should be described. You should
include only the information which was provided in the case study, do not include
additional data. Record observations for the following systems if applicable to this patient
encounter (there are 12 possible systems for examination): Constitutional (e.g. vita! signs,
general appearance), Eyes, ENT/mouth, Cardiovascular, Respiratory, GI, GU,
Musculoskeletal, Skin, Neurological, Psychiatric,
Hematological/lymphatic/immunologic/lab testing. The focused PE should only include
systems for which you have been given data. NOTE: Cardiovascular and Respiratory

3. systems should be assessed on every patient regardless of the chief complaint. Testing
Results: Results of any diagnostic or lab testing ordered during that patient visit. A:
ASSESSMENT: (this is your diagnosis (es) with the appropriate ICD 10 code) List and
number the possible diagnoses (problems) you have identified. MSN5600L Acute Diseases
DiscussionThese diagnoses are the conclusions you have drawn from the subjective and
objective data. Remember: Your subjective and objective data should your diagnoses and
your therapeutic plan. Do not write that a diagnosis is to be “ruled out” rather state the
working definitions of each differential or primary diagnosis (es). For each diagnoses
provide a cited rationale for choosing this diagnosis. This rationale includes a one sentence
cited definition of the diagnosis (es) the pathophysiology, the common signs and symptoms,
the patients presenting signs and symptoms and the focused PE findings and tests results
that the dx. Include the interpretation of all lab data given in the case study and explain
how those results your chosen diagnosis. P: PLAN (this is your treatment plan specific to
this patient). Each step of your plan must include an EBP citation. 1. Medications write out
the prescription including dispensing information and provide EBP to ordering each
medication. Be sure to include both prescription and OTC medications. 2. Additional
diagnostic tests include EBP citations to ordering additional tests 3. Education this is part
of the chart and should be brief, this is not a patient education sheet and needs to have a
reference. 4. Referrals include citations to a referral 5. Follow up. Patient follow-up should
be specified with time or circumstances of return. You must provide a reference for your
decision on when to follow up. (Student Name) Miami Regional University Date of
Encounter: Preceptor/Clinical Site: Clinical Instructor: Dr. David Trabanco DNP, APRN,
AGNP-C, FNP-C Soap Note # Main Diagnosis ( Exp: Soap Note #3 DX: Hypertension)
PATIENT INFORMATION Name: Mr. DT Age: 68-year-old Gender at Birth: Male Gender
Identity: Male Source: Patient Allergies: PCN, Iodine Current Medications: • Atorvastatin tab
20 mg, 1-tab PO at bedtime • ASA 81mg po daily • Multi-Vitamin Centrum Silver PMH:
Hypercholesterolemia Immunizations: Influenza last 2018-year, tetanus, and hepatitis A
and B 4 years ago. Preventive Care: Coloscopy 5 years ago (Negative) Surgical History:
Appendectomy 47 years ago. Family History: Father- died 81 does not report information
Mother-alive, 88 years old, Diabetes Mellitus, HTN Daughter-alive, 34 years old, healthy
Social History: No smoking history or illicit drug use, occasional alcoholic beverage
consumption on social celebrations. Retired, widow, he lives alone. Sexual Orientation:
Straight Nutrition History: Diets off and on, Does not each seafood Subjective Data: Chief
Complaint: “headaches” that started two weeks ago Symptom analysis/HPI: The patient is
65 years old male who complaining of episodes of headaches and on 3 different occasions
blood pressure was measured, which was high (159/100, 158/98 and 160/100
respectively). Patient noticed the problem started two weeks ago and sometimes it is
accompanied by dizziness. He states that he has been under stress in his workplace for the
last month. Patient denies chest pain, palpitation, shortness of breath, nausea or vomiting.
Review of Systems (ROS) CONSTITUTIONAL:MSN5600L Acute Diseases DiscussionDenies
fever or chills. Denies weakness or weight loss. NEUROLOGIC: Headache and dizziness as
describe above. Denies changes in LOC. Denies history of tremors or seizures. HEENT:
HEAD: Denies any head injury, or change in LOC. Eyes: Denies any changes in vision,

4. diplopia or blurred vision. Ear: Denies pain in the ears. Denies loss of hearing or drainage.
Nose: Denies nasal drainage, congestion. THROAT: Denies throat or neck pain, hoarseness,
difficulty swallowing. RESPIRATORY: Patient denies shortness of breath, cough or
hemoptysis. CARDIOVASCULAR: No chest pain, tachycardia. No orthopnea or paroxysmal
nocturnal dyspnea. GASTROINTESTINAL: Denies abdominal pain or discomfort. Denies
flatulence, nausea, vomiting or diarrhea. GENITOURINARY: Denies hematuria, dysuria or
change in urinary frequency. Denies difficulty starting/stopping stream of urine or
incontinence. MUSCULOSKELETAL: Denies falls or pain. Denies hearing a clicking or
snapping sound. SKIN: No change of coloration such as cyanosis or jaundice, no rashes or
pruritus. Objective Data: VITAL SIGNS: Temperature: 98.5 °F, Pulse: 87, BP: 159/92 mmhg,
RR 20, PO2-98% on room air, Ht- 6’4”, Wt 200 lb, BMI 25. Report pain 2/10. GENERAL
APPREARANCE: The patient is alert and oriented x 3. No acute distress noted.
NEUROLOGIC: Alert, CNII-XII grossly intact, oriented to person, place, and time. Sensation
intact to bilateral upper and lower extremities. Bilateral UE/LE strength 5/5. HEENT: Head:
Normocephalic, atraumatic, symmetric, non-tender. Maxillary sinuses no tenderness.
Eyes:MSN5600L Acute Diseases DiscussionNo conjunctival injection, no icterus, visual
acuity and extraocular eye movements intact. No nystagmus noted. Ears: Bilateral canals
patent without erythema, edema, or exudate. Bilateral tympanic membranes intact, pearly
gray with sharp cone of light. Maxillary sinuses no tenderness. Nasal mucosa moist without
bleeding. Oral mucosa moist without lesions,. Lids non-remarkable and appropriate for
race. Neck: supple without cervical lymphadenopathy, no jugular vein distention, no thyroid
swelling or masses. CARDIOVASCULAR: S1S2, regular rate and rhythm, no murmur or gallop
noted. Capillary refill < 2 sec. RESPIRATORY: No dyspnea or use of accessory muscles
observed. No egophony, whispered pectoriloquy or tactile fremitus on palpation. Breath
sounds presents and clear bilaterally on auscultation. GASTROINTESTINAL: No mass or
hernia observed. Upon auscultation, bowel sounds present in all four quadrants, no bruits
over renal and aorta arteries. Abdomen soft non-tender, no guarding, no rebound no
distention or organomegaly noted on palpation MUSKULOSKELETAL: No pain to palpation.
Active and passive ROM within normal limits, no stiffness. INTEGUMENTARY: intact, no
lesions or rashes, no cyanosis or jaundice. ASSESSMENT: Main Diagnosis Essential
(Primary) Hypertension (ICD10 I10): Given the symptoms and high blood pressure (156/92
mmhg), classified as stage 2. Once the organic cause of hypertension has been ruled out,
such as renal, adrenal or thyroid, this diagnosis is confirmed (Codina Leik, 2015). Diagnosis
is based on the clinical evaluation through history, physical examination, and routine
laboratory tests to assess risk factors, reveal identifiable causes and detect target-organ
damage, including evidence of cardiovascular disease (Domino et al,. 2017). Differential
diagnosis: ? Renal artery stenosis (ICD10 I70.1) ? Chronic kidney disease (ICD10 I12.9) ?
Hyperthyroidism (ICD10 E05.90) PLAN: Labs and Diagnostic Test to be ordered: • CMP •
Complete blood count (CBC) • Lipid profile • Thyroid-stimulating hormone (TSH) •
Urinalysis with Micro • Electrocardiogram (EKG 12 lead) Pharmacological treatment: •
Hydrochlorothiazide tab 25 mg, Initial dose: 25 mg orally once daily. • Lisinopril 10mg PO
Daily Non-Pharmacologic treatment: • Weight loss • Healthy diet (DASH dietary pattern):

5. Diet rich in fruits, vegetables, whole grains, and low-fat dairy products with reduced
content of saturated and trans l fat MSN5600L Acute Diseases Discussion