NR511 – Differential Diagnosis and Primary Care Essay Assignment Papers and Discussions
Syllabus
Course Code: NR511
Course Title: Differential Diagnosis and Primary Care
Top Information
Course Number: NR511
Course Title: Differential Diagnosis and Primary Care
Course Credit: 3 (Theory 0.5; Clinical 2.5)
Pre-requisite: NR508, NR509
ORDER A PLAGIARISM-FREE PAPER NOW
Course Text
Textbook 1
Dunphy, L. M., Winland-Brown, J. E., Porter, B. O., & Thomas, D. J. (2015). Primary care: The art and science of advanced practice nursing (4th ed.). Retrieved from http://online.vitalsource.com
Textbook 2
Ferri, F. F. (2014). Ferri’s clinical advisor 2014: 5 books in 1. Philadelphia: Mosby Elsevier. (Ebook)
Textbook 3
Jarvis, C. (2016). Physical examination & health assessment (7th ed.). Retrieved from http://online.vitalsource.com.(Ebook)
Required across all FNP courses:
Textbook 4
American Psychological Association. (2010). Publication manual of the American Psychological Association (6th ed.). Washington, DC: Author.
NR511 Syllabus
Course Description
This course will provide students with content regarding formulating differential diagnoses of individuals within the primary care setting, along with an introduction to critical diagnostic skills to cultivate evidence-based behaviors. An emphasis will be placed on processing client information in a logical, progressive manner and formulating differential diagnoses for individuals across the lifespan. The course will include 125 hours of supervised clinical practicum in primary care.
Course Outcomes
1. Demonstrate diagnostic reasoning that will assist in health promotion and illness management of common health problems in primary care through case study presentation. (PO 1)
2. Plan for healthcare delivery in an evidence-based manner to support high-quality and cost-effective care and decision-making. (PO 1, 9, 11)
3. Formulate differential diagnoses based on the subjective and objective patient data obtained from the case study. (PO 1, 3)
4. Create weekly S-O-A-P documentation on a clinical patient, demonstrating increased mastery each week. (PO 1, 3)
5. Create a plan of care which integrates pharmacological, complementary, and nonpharmacological therapies for management of common health problems. (PO 1)
6. Utilize established standards and guidelines for management of common pediatric, gynecology, internal medicine, and behavioral conditions in primary care. (1, 11)
7. Engage in sequential application of selected advanced skills/procedures. (PO 1) 8. Demonstrate advanced skills/procedures for quality outcomes pertinent to patient care. (PO 1, 2)
9. Perform selected advanced skills/procedures appropriate to student competence and provider scope of practice. (1)
10. Conduct a systematic and accurate assessment of a client’s total health status, utilizing appropriate interviewing and data collection techniques. (PO 1, 2, 5, 11). NR511 – Differential Diagnosis and Primary Care Essay Assignment Papers and Discussions.
11. Reflect on personal and professional growth toward achieving competence as a family nurse practitioner. (PO 5, 7)
Program Outcomes
The MSN program outcomes are aligned with the American Association of Colleges of Nursing publication, The Essentials of Master’s Education in Nursing (2011). Upon completion of the MSN degree program, the graduate will be able to:
1. Practice safe, high-quality advanced nursing care based on concepts and knowledge from nursing and related disciplines.
2. Construct processes for leading and promoting quality improvement and safety in advanced nursing practice and healthcare delivery.
3. Use contemporary communication modalities effectively in advanced nursing roles.
4. Evaluate the design, implementation and outcomes of strategies developed to meet healthcare needs.
5. Develop a plan for lifelong personal and professional growth that integrates professional values regarding scholarship, service and global engagement.
6. Apply legal, ethical and human-caring principles to situations in advanced nursing practice.
7. Design patient-centered care models and delivery systems using the best available scientific evidence.
8. Manage human, fiscal and physical resources to achieve and support individual and organizational goals.
9. Compose a plan for systematic inquiry and dissemination of findings to support advanced nursing practice, patient-care innovation, and the nursing profession.
10. Collaborate interprofessionally in research, education, practice, health policy and leadership to improve population health outcomes.
11. Apply principles of informatics to manage data and information in order to support effective decision making.
Course Schedule
Week 1
Title: Primary Care in the 21st Century, Caring and the Advanced Practice Nurse, and the Art of Diagnosis and Treatment
COs: 3, 6, 8
Reading: Dunphy, L. M., Winland-Brown, J. E.,
Porter, B. O., & Thomas, D. J. (2015).
Primary care: The art and science of
advanced practice nursing (4th ed.).
Retrieved from
http://online.vitalsource.com
Chapter 1: Primary Care in the
Twenty-First Century: A Circle
of Caring
Chapter 4: The Art of
Diagnosis and Treatment
Chapter 8: Eyes, Ears, Nose,
and Throat Problems
Assignments: Attestation Statement Completion
(required to begin course)
Clinical Encounter Log in eLogs with
SOAP note (required, but not graded)
Case Study
Discussions
Yes
Other
Retrieved on 1/16
Week 2
Title: Evidence Based Practice,
Neurological Problems, and Eyes,
Ears, Nose, and Throat Problems
COs: 4, 6, 9, 10
Reading: Dunphy, L. M., Winland-Brown, J. E.,
Porter, B. O., & Thomas, D. J. (2015).
Primary care: The art and science of
advanced practice nursing (4th ed.).
Retrieved from
http://online.vitalsource.com
Chapter 5: Evidence-Based
Care
Chapter 6: Neurologic
Problems
Assignments: Clinical Encounter Log in eLogs with
SOAP note (required, but not graded)
Case Study
Discussions
Yes
Other
Week 3
Title: Health Promotion, Skin Problems, and
Respiratory Problems
COs: 4, 5, 7, 8, 9
Reading: Dunphy, L. M., Winland-Brown, J. E.,
Porter, B. O., & Thomas, D. J. (2015).
Primary care: The art and science of
advanced practice nursing (4th ed.).
Retrieved from
http://online.vitalsource.com
Chapter 3: Health Promotion
Chapter 7: Skin Problems
Chapter 9: Respiratory
Problems
Assignments: Clinical Encounter Log in eLogs with
SOAP note(required, but not graded)
Case Study
Discussions
Yes
Other
Week 4
Title: Diagnostic Testing, Cardiovascular
Retrieved on 1/16
Problems, Abdominal Problems,
Renal Problems
COs: 2, 5, 7, 8, 9
Reading: Dunphy, L. M., Winland-Brown, J. E.,
Porter, B. O., & Thomas, D. J. (2015).
Primary care: The art and science of
advanced practice nursing (4th ed.).
Retrieved from
http://online.vitalsource.com
Chapter 10: Cardiovascular
Problems
Chapter 11: Abdominal
Problems
Chapter 12: Renal Problems
Assignments: Clinical Encounter Log in eLogs with
SOAP note (required, but not graded)
Quiz (required but not graded)
Case Study
Discussions
Yes
Other
Week 5
Title: Men’s Health Problems, Women’s
Health Problems, Musculoskeletal
Problems
COs: 3, 5, 6, 7, 8, 9
Reading: Dunphy, L. M., Winland-Brown, J. E.,
Porter, B. O., & Thomas, D. J. (2015).
Primary care: The art and science of
advanced practice nursing (4th ed.).
Retrieved from
http://online.vitalsource.com
Chapter 13: Men’s Health
Problems
Chapter 14: Women’s Health
Problems
Chapter 15: Musculoskeletal
Problems
Assignments: Clinical Encounter Log in eLogs
(required, but not graded)
Case Study
Discussions
Yes
Other
Retrieved on 1/16
Week 6
Title: Complex Diagnosis, Endocrine and
Metabolic Problems, Hematologic and
Immune Problems, and Emergency
Problems
COs: 2, 5, 7, 8, 9
Reading: Dunphy, L. M., Winland-Brown, J. E.,
Porter, B. O., & Thomas, D. J. (2015).
Primary care: The art and science of
advanced practice nursing (4th ed.).
Retrieved from
http://online.vitalsource.com
Chapter 16: Endocrine and
Metabolic Problems
Chapter 17: Hematologic and
Immune Problems
Chapter 19: Emergency
Problems
Assignments: Clinical Encounter Log in eLogs
(required, but not graded)
Case Study
Discussions
Yes
Other
Week 7
Title: Laboratory tests, Psychological
Problems, Palliative Care and
Practical Psychotherapy
COs: 1, 3, 5, 7, 8, 9
Reading: Dunphy, L. M., Winland-Brown, J. E.,
Porter, B. O., & Thomas, D. J. (2015).
Primary care: The art and science of
advanced practice nursing (4th ed.).
Retrieved from
http://online.vitalsource.com
Chapter 18: Psychosocial
Problems
Chapter 20: Palliative Care
Chapter 23: The 15-Minute
Hour: A Short-Term Approach
to Psychotherapy in Primary
Care
Assignments: Clinical Encounter Log in eLogs
(required, but not graded)
Case Study
Discussions
Yes
Other
Retrieved on 1/16
Week 8
Title: Ethical and Legal Issues, the Business
of Advanced Practice, Putting Caring
into Practice: Caring for Self
COs: 11
Reading: Dunphy, L. M., Winland-Brown, J. E.,
Porter, B. O., & Thomas, D. J. (2015).
Primary care: The art and science of
advanced practice nursing (4th ed.).
Retrieved from
http://online.vitalsource.com
Chapter 21: Ethical and Legal
Issues of a Caring-Based
Practice
Chapter 22: The Business of
Advanced Practice
Chapter 24: Putting Caring Into
Practice: Caring for Self
Assignments: Clinical Encounter Log in eLogs &
Clinical Performance Evaluation
(graded)
Quiz (required but not graded)
Reflection (graded)
Reflection Yes
Other
Late Assignment Policy
Students are expected to submit assignments by the time they are due. Assignments submitted
after the due date and time will receive a deduction of 10% of the total points possible for that
assignment for each day the assignment is late. Assignments will be accepted, with penalty as
described, up to a maximum of three days late, after which point a zero will be recorded for the
assignment.
In the event of an emergency that prevents timely submission of an assignment, students may
petition their instructor for a waiver of the late submission grade reduction. The instructor will
review the student’s rationale for the request and make a determination based on the merits of
the student’s appeal. Consideration of the student’s total course performance to date will be a
contributing factor in the determination. Students should continue to attend class, actively
participate, and complete other assignments while the appeal is pending.
This Policy applies to assignments that contribute to the numerical calculation of the course
letter grade.
Retrieved on 1/16
Evaluation Methods
Assignment Points Weighting
Case Study Discussions
(100 points, Weeks 1–7)
700 70%
Reflection
(due Week 8)
50 5%
Quiz
(required, but not graded due
Week 4 & 8)
N/A N/A
Clinical Encounter Log
(due Weeks 1–8)
Clinical Performance Evaluation
(Week 8)
Final clinical performance
evaluation pass and/or
documentation of 125 hours =
250 points
Fail or unsatisfactory on clinical
performance evaluation and/or
less than 125 hours
documented =0 points
250 25%
Total Points 1,000 100%
A passing grade, or S, must be achieved on the clinical performance evaluation. If this is
achieved and the 125 clinical hours are documented, the 250 points will be added to the
remainder of the course points to calculate the final course grade. If the student does not
achieve a passing grade (fail) for the clinical performance evaluation, then the final
course grade assigned will be F.
No extra credit assignments are permitted for any reason.
All of your course requirements are graded using points. At the end of the course, the points are
converted to a letter grade using the scale in the table below. Percentages of 0.5% or higher are
Retrieved on 1/16
not raised to the next whole number. A final grade of 76% (letter grade C) is required to pass
the course.
LETTER
GRADE POINTS PERCENTAGE
A 940–1,000 94–100%
A- 920–939 92–93%
B+ 890–919 89–91%
B 860–889 86–88%
B- 840–859 84–85%
C+ 810–839 81–83%
C 760–809 76–80%
F 759 and below 75% and below
Students agree that, by taking this course, all required papers may be subject to submission for textual similarity review to Turnitin.com for the detection of plagiarism. All submitted papers will be included as source documents in the Turnitin.com reference database solely for the purpose of detecting plagiarism of such papers. Use of the Turnitin.com service is subject to the Terms and Conditions of Use posted on the Turnitin.com site.
Participation Guidelines
The weekly case study discussion is worth up to 100 points. Students are expected to participate a minimum of four times (once in part one by Tuesday, 11:59 p.m. MT, once in part
two by Thursday, 11:59 p.m. MT, provide a written summary in SOAP format to the Dropbox by Sunday, 11:59 p.m. MT, and one post to a student peer as required in the interactive dialogue criterion). The student must provide answers to the graded case study questions from part one, post a treatment plan for part two and provide a written summation of their case in SOAP format to the Dropbox for part three.
Grading Rubric
Criteria
Exceptional
Outstanding or
highest level of
performance
Exceeds
Very good or
high level of
performance
Meets
Satisfactory
level of
performance
Needs
Improvements
Poor or
failing level of
performance
Developing
Unsatisfactory
level of
performance
Total Points
Possible=
100
24 Points 21 Points 19 Points 9 Points 0 Points
Application
of Course
Knowledge
Post contributes
unique
perspectives or
Post
contributes
unique
Post has
limited
perspective,
Post
perspectives
are not
Post offers no
insight or
application to
Retrieved on 1/16
Criteria
Exceptional
Outstanding or
highest level of
performance
Exceeds
Very good or
high level of
performance
Meets
Satisfactory
level of
performance
Needs
Improvements
Poor or
failing level of
performance
Developing
Unsatisfactory
level of
performance
insights
applicable to the
results from the
physical exam
differential
diagnoses.
Part One: Initial
post includes at
least three (3)
differential
diagnoses with
rationale for
each problembased
learning
case study
patient and
answers all
questions
presented in the
case.
Parts Two and
Three:
Presumptive
diagnosis and
treatment plan
are appropriate
and evidence
based for each
case study
patient.
perspectives
or insights,
but may lack
some
applicability to
presented
case study
patients.
Part One:
Initial post
includes at
least two (2)
differential
diagnoses
with rationale
for each
problembased
learning case
study patient
and answers
most of the
questions
presented in
the case.
Parts Two
and Three:
Confirmed
diagnosis and
treatment plan
partially
applicable
and evidence
based for
each case
study patient.
insights
and/or
applicability to
presented
case study
patients.
Part One:
Initial post
does not
address each
patient or
does not
include at
least two (2)
differential
diagnoses for
each patient.
Some
evidencebased
rationale may
be missing.
Does not
answer
questions
presented in
the case.
Parts Two and
Three:
Confirmed
diagnosis and
treatment plan
are not
applicable or
may not be
evidencebased.
consistent with
current
practice.
the case study
presentation
24 Points 21 Points 19 Points 9 Points 0 Points
Support from
EvidenceBased
Initial discussion
posts in parts
one, two and
Initial
discussion
posts for parts
Initial
discussion
posts for parts
Citations to
non-scholarly
websites given
Discussion
posts contain
no evidence-
Retrieved on 1/16
Criteria
Exceptional
Outstanding or
highest level of
performance
Exceeds
Very good or
high level of
performance
Meets
Satisfactory
level of
performance
Needs
Improvements
Poor or
failing level of
performance
Developing
Unsatisfactory
level of
performance
Practice
(EBP)
SOAP note are
supported by
evidence from
appropriate
sources
published within
the last 5 years.
In-text citations
and full
references are
provided
one, two, and
SOAP note
are partially
supported by
evidence from
appropriate
sources
published
within the last
5 years.
In-text
citations and
full references
are provided.
Evidencebased,
peer
reviewed
journal article
cited but may
not fully
support the
treatment
plan.
one, two, and
SOAP note
are partially
supported by
evidence.
Sources may
not be
scholarly in
nature or may
be older than
5 years.
In-text
citations
and/or full
references
may be
incomplete or
missing.
as rationale to
support
differential
diagnoses
and/or
treatment plan.
based practice
reference or
citation.
24 Points 21 Points 19 Points 9 Points 0 Points
Organization
Discussion
posts and
SOAP notes
presents case
study findings in
a logical,
meaningful, and
understandable
sequence. Each
problem-based
learning case
study patient is
presented
individually in all
discussion
posts and
SOAP notes.
Part One:
Discussion
posts and
SOAP notes
are relevant to
the topic but
may be
unclear or
difficult to
follow in
places.
Part One:
Discussion
questions
may not be
addressed
individually for
each patient.
SOAP note
Discussion
posts and
SOAP notes
not fully
relevant to the
topic. May be
unclear or
difficult to
follow in
places.
SOAP note
does not
contain all
components
and/or may be
missing data.
Discussion post
presents case
findings and
plan or
intervention
that are
sometimes
unclear to
follow and may
not always be
relevant to topic
Discussion post
is not relevant
to case study.
Retrieved on 1/16
Criteria
Exceptional
Outstanding or
highest level of
performance
Exceeds
Very good or
high level of
performance
Meets
Satisfactory
level of
performance
Needs
Improvements
Poor or
failing level of
performance
Developing
Unsatisfactory
level of
performance
Discussion
questions
addressed
individually for
each patient.
contains all
elements but
may not be
written
following
SOAP note
format.
24 Points 21 Points 19 Points 9 Points 0 Points
Interactive
Dialogue
Presents case
study findings
and responds
substantively to
at least one
topic-related
post of a peer
including
evidence from
appropriate
sources, and all
direct faculty
questions
posted in parts
one and two.
Presents case
study findings
and responds
substantively
to at least one
topic-related
post of a peer.
Does not
include
evidence from
appropriate
sources.
Responds to
some direct
faculty
questions
posted in
parts one and
two.
Responds to a
student peer
and/or faculty
questions but
the posts add
limited content
or insights to
the
discussion.
Responds to a
student peer
and/or faculty,
but the nature
of the response
is not
substantive.
Does not
respond to a
topic-related
peer post
and/or does not
respond to
faculty
questions
posted by
Sunday.
4 Points 3 Points 2 Points
1 Point
0 Points
Grammar,
Syntax, APA
APA format,
grammar,
spelling, and/or
punctuation are
accurate, or
with zero to one
errors.
Two to four
errors in APA
format,
grammar,
spelling, and
syntax noted.
Five to seven
errors in APA
format,
grammar,
spelling, and
syntax noted.
Eight to nine
errors in APA
format,
grammar,
spelling, and
syntax noted.
Post contains
greater than ten
errors in APA
format,
grammar,
spelling, and/or
punctuation or
Retrieved on 1/16
Criteria
Exceptional
Outstanding or
highest level of
performance
Exceeds
Very good or
high level of
performance
Meets
Satisfactory
level of
performance
Needs
Improvements
Poor or
failing level of
performance
Developing
Unsatisfactory
level of
performance
repeatedly
makes the
same errors
after faculty
feedback.
0 Points
Deducted
-10 Points per
Discussion
Part
Participation
Enters first
post to part
one by 11:59
p.m. MT on
Tuesday;
First post to
part two by
11:59 p.m. MT
on Thursday;
and submits
written
summation
by Sunday
11:59 p.m.
MT. Written
submission
(SOAP notes)
will NOT be
accepted
after Sunday
11:59 p.m.
MT.
* 10 points
deducted per
discussion
part if this
criteria is not
met.
Enters first post
to part one by
11:59 p.m. MT
on Tuesday;
first post to part
two by 11:59
p.m. MT on
Thursday; and
submits written
summation by
Sunday 11:59
p.m. MT.
10 points
deducted per
discussion part
if this criteria is
not met.
Written
submission will
not be accepted
after Sunday
11:59 p.m. MT.
33 points
deducted for
missing SOAP
note.
Retrieved on 1/16
Webliography Disclaimer
The purpose of the Webliography is to provide students with annotated bibliographies of world
wide websites relevant to their courses. These websites are not meant to be all inclusive of what
is available for each course’s subjects and have not been sanctioned as academically rigorous
or scholarly by Chamberlain College of Nursing. Please exercise caution when using these
websites for course assignments and references.
Professional Portfolio
Select assignments from courses across the FNP program will be compiled as artifacts within a
Professional Portfolio to demonstrate your professional growth and expertise. Your final
portfolio, which will be submitted in the final course NR661, will be assessed against the
learning outcomes of the program. The Professional Portfolio will include the following:
Reflections from Week 8 for all FNP courses
Five exemplar case studies (student selects top five)
eLogs portfolio
Curriculum vitae
Professional development plan paper from NR510
NR511 – Differential Diagnosis and Primary Care Essay Assignment Papers and Discussions
Family practice clinic which employs physicians and nurse practitioners. Today is another busy in your family practice clinic. You note your next visit is a “2fer”. This means you have two patients to see in this visit. You ask your medical assistant to tell you why they are here. Your medical assistant tells you the patients are daughter and father. The daughter has burning with urination and the dad came along for the visit because he has some back pain. You review the chart before entering the room to familiarize yourself with these patients. When you enter the room you note a Caucasian woman who appears to be about 40 years old. She is well groomed and appropriately dressed for the weather. She is sitting in the chair. The man is well groomed, appears to be about 70 years old, and is sitting on the exam table leaning forward. You introduce yourself as you always do and ask what brings them to the clinic today.
NR511 – Differential Diagnosis and Primary Care Essay Assignment Papers and Discussions
PMH Age 44. No chronic illness or injuries. Recently treated for strep throat with a 10 day course of penicillin. Completed 1 day ago. Hospitalized x 2 for childbirth, no surgeries. NKDA. Drinks alcohol socially, denies tobacco or illicit drug use. Sleeps 6-7 hours/night. No current medications. Takes a daily multivitamin and a B complex vitamin.
NR511 – Differential Diagnosis and Primary Care Essay Assignment Papers and Discussions
Mary is married with four children ages 4-9. She works full time. Mary’s parents Katie and John also live in the home. Both are retired and help with childcare and household needs since both parents work full time. Her husband and father both smoke but not in the house.
NR511 – Differential Diagnosis and Primary Care Essay Assignment Papers and Discussions
PMH Age 75. Has HTN and hyperlipidemia. No previous injuries. No hospitalizations or surgeries. Takes Lipitor 40 mg daily and Lisinopril/HCTZ 20, 12.5 daily. Allergic to Bactrim. Sleeps 6-7 hours a night. Social Born in Ireland, has lived in America for 45 years. Lives with his wife in his daughter and son in laws home. Retired carpenter. Helps with the kids by taking them to school and after school activities. Enjoys gardening and fixing things around the house. Drinks ETOH on the weekends and smokes 1 pack a day. Denies other drug use. FMH Parents lived until their 80’s. Has 13 siblings, most are alive. One brother died suddenly of a heart attack age 45 and lost a sister at age 4 to consumption. No family health problems except for high blood pressure when they get older.
Discussion part one: What further questions do you have forMary at this visit? Use OLDCARTS to guide your questions. Link the questions to your differential diagnoses. What is your differential diagnosis list with ICD 10 for this visit thus far? Each differential diagnosis should include a one sentence pathophysiology statement supported by the literature. List the patient’s signs and symptoms and include a rationale statement that explains how the diagnosis is appropriate for your patient. Based on your differential diagnoses list, what focused PE would you perform? What labs or diagnostic tests, if any, would you order? What further questions do you have forJohn at this visit? Use OLDCARTS to guide your questions. Link the questions to your differential diagnoses. What is your differential diagnosis list with ICD 10 for this visit thus far? Each differential diagnosis should include a one sentence pathophysiology statement supported by the literature. List the patient’s signs and symptoms and include a rationale statement that explains how the diagnosis is appropriate for your patient. Based on your differential diagnoses list, what focused PE would you perform? What labs or diagnostic tests, if any, would you order?
Interview: Her last menstrual period (LMP) was two weeks ago. No reports of headache or vision changes. No fever, chills, nausea or vomiting. No ear pain. No reports of nasal congestion, or discharge No report of wheezing or shortness of breath. No reports of chest pain, palpitation, dizziness or enlarged lymph nodes. No reports of heartburn, or indigestion. Reports vulvar itching and burning with urination x 2 days. No reports of incontinence. No back pain. Feels “not right”. Is sexually active, denies dyspareunia. Has tried drinking more water, Monistat cream and cranberry pills. Nothing has really seemed to work, nothing makes it feel better.
Based on reports of vulvar itching you perform a pelvic exam. Vulva with erythema and excoriation noted, most likely due to scratching. Urethra without swelling or discharge noted. Bartholin glands nontender, no enlargement bilaterally. Thick white curdy discharge noted in vagina, vaginal walls, erythema noted. Cervix pink, midline, smooth without excoriation, parous os, secretions cloudy, thick, stringy without odor. Bimanual exam: no pain with cervical palpation, uterus and ovaries not enlarged. Wet prep: negative clue cells, positive hyphae. pH 4.0 Whiff negative
Height 5 feet 7 inches weight 195 pounds T 98.4, BP 150/84, P 90, R 20. Focused exam General: Alert, oriented and cooperative. Cardiopulmonary: Heart S1 and S2 noted, RRR, no murmurs, noted. Lungs clear to auscultation bilaterally. Respirations unlabored. Back: skin intact, warm and dry, no petecchiae, lesions or masses noted. Patellar reflexes brisk bilaterally. Normal spinal curvature. Tenderness noted upon palpation of left side lateral to lumbar spine. Straight leg raise is negative bilaterally. ROM: Unable to touch his toes, flexion is about 45 degrees. Gait is slow and appears unable to stand up straight, he is leaning forward slightly when walking.
Discussion Part Two Summarize the history and results of the physical exam for each patient in a separate SOAP note for each case study patient. Calculate the BMI for each patient. List the primary diagnosis with ICD10 code. Include your rationale for choosing the primary diagnosis. The diagnostic rationale in the assessment section should include your patients’ symptoms, exam findings and the interpretation of all presented lab findings. Include one evidence-based journal article or clinical guideline that supports your rationale for each patient. Develop a complete evidence-based treatment (EBP) plan for each patient that includes medications, any additional diagnostic tests, patient education, possible referrals, and a plan for follow up with you, the PCP. Each step of the plan must include an in-text citation to an approved reference as listed on the Reference Guidelines document. The guidelines for SOAP note documentation is located under Course Resources and can assist you in writing this post and your SOAP note.