NURS 6512 Focused Soap Note Musculoskeletal and Neurologic Disorders
NURS 6512 Focused Soap Note Musculoskeletal and Neurologic Disorders
NURS 6512 Focused Soap Note Musculoskeletal and Neurologic Disorders essay assignment
Case Study Week Ten: Focused Soap Note
CC:
HPI: Will is a 69-year-old Asian male with a history of a right-hand tremor for several years. He is accompanied by his wife today to the clinic. She is very concerned because Tony has been having difficulty with balance and walking, which is becoming slower. This morning he fell while walking across the room. She saw nothing to cause him to trip. The floor is hardwood and all rugs have been removed by his wife due to concerns for falling. He does not use a cane or walker. He was \”in a rush to get to the bathroom.\” He is not complaining of inability to move but he is cradling his right wrist in his left hand. He reports pain in his right arm that is \”like an ache but not enough that he took pain medication prior to coming to the clinic. Both tell you that he fell onto his right side, did not bump his head and was not unconscious after the fall. He was wearing his usual comfortable shoes that are his favorites.
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You suspect Parkinson’s disease (PD) and wonder if he has had an examination in the past that may have found signs and symptoms of PD. Briefly describe the etiology of PD. You note from the chief complaint that he fell. What is the relationship between PD and falls? What do you consider regarding his hurry to get to the bathroom?
The remainder of the history indicates that his family history has his parents living into their 90s until they had strokes. He takes no medications except Tylenol for occasional pain. He has not seen a provider since his retirement physical five years ago.He is active in the home, taking care not to fall, but does not use a cane of walker. He is a retired teacher and is actively involved in a reading group as a hobby. He has been married to his wife for 50 years, she also is a retired teacher, and they have a comfortable retired lifestyle, owning a home in a neighborhood where they have many friends who also are Asian. No children. The remainder of the ROS does not contribute to or support the current problem.
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PE: What would be the priority examination given his chief complaint?
What will you examine in the musculoskeletal examination?
What will you examine in the neurological examination of Will? Describe at least three neurological examinations you will perform.
Are there any other examinations that you will consider?
Diagnostics: You know that PD is primarily a clinical diagnosis, but there are several diagnostic tests that can be useful in making the diagnosis. Describe at least two diagnostic tests that may be helpful in the diagnosis of PD. Also you want to determine if there was an injury from the fall.
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You understand that there was a fall with a denial of injury and pain that did not require pain medication. Are there diagnostics you would consider?
You understand that he fell on his way to the bathroom apparently with a quickened gait. Diagnostics?
Differential Diagnoses: There are at least three to consider. Describe each and your rationale for considering them. Is it possible that he has more than one diagnosis? Are they interrelated with his chief complaint?
Diagnosis: If you diagnose Tony with early-stage PD. What are some of the key principles of treatment? List at least two principles of treatment.
If you diagnose a musculoskeletal problem what would be the treatment for that?
If there are other diagnoses how would you determine to treat or not to treat?
NURS 6512 Focused Soap Note Musculoskeletal and Neurologic Disorders assignment
Plan/Referrals:
If as an NP you decide not to initiate treatment for PD. what would you do instead?
Would you treat any other problem? Diagnostic reports? The rationale for treating or not treating.
Describe at least three referrals and the rationale for each.
What patient education will you offer the couple, taking into consideration social determinants of health (would you ask additional questions regarding SDH?
Follow-up: You suggest you will want to see him again in 1 month or sooner if there is a need. What are some of the things you will want to follow in addition to his musculoskeletal and neurological status? List at least three questions you will explore as you discharge him home with a referral.
Remember, the reflection is required as it is your understanding of what you learned from the case, how you were able to integrate potentially three separate diagnoses, and their relationship to the final disposition of the patient, and how you will use the knowledge you gained as well as any other comments you would like to make regarding the case.