MSN History and Physical Examination Case Write Up Assignment Sample Solution IncludedThe purpose of

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MSN History and Physical Examination Case Write Up Assignment Sample Solution Included

The purpose of the MSN History and Physical Examination Case Write Up Assignment is for your instructor to “see” what you are doing in clinical and “see” how you are making clinical decisions. For these write-ups, you will select a patient seen in your current clinical rotation. You will “write-up” the visit, omitting any identifying patient factors. In future semesters, you will continue to build on your write-ups and demonstrate comprehensive advanced practice thinking.

Make sure to start “fresh”. Do not copy and paste from any examples, templates, other students work or even your own work. Be honest in your write-up. If you realize that you have forgotten to assess something or forgot a certain part of the teaching, just add an Addendum at the bottom of the write-up saying what should have been done. Your clinical faculty do not expect perfect write-ups but do expect that you use every patient encounter and subsequent write-up as a time to learn and to evaluate and improve your own practice.

Note that you CANNOT redo write-ups. A grade cannot be improved by redoing a write-up. Faculty will not read and comment on rough drafts of write-ups

All case write-ups are to be submitted to the appropriate assignment category by the due date. Late submissions to the appropriate assignment category will incur a 5pt/day penalty (no maximum) including weekends unless an extension has been requested and approved at least 72 hours before due date.

When submitting case write-up in Blackboard, the assignment will submit to a plagiarism detection software. The plagiarism detection software is used by HBU to identify plagiarized assignments. We are aware of the difference between high “copy matches” due to copied things such as titles/headings and significant matches that were inappropriately copied from another paper. If a paper has significant or complete sections of copied material, a grade of zero will incur.

These write-ups will require a complete history, head-to-toe or extensive ROS and physical examination (PE). Visits that may necessitate a comprehensive ROS, physical exam, and write-up include annual physical, well-woman exam (may not always include head to toe, but could be the only preventive care most women receive), well-child exam, new or established patients with complex or chronic diseases or comorbidities, non-specific complaints, such as fatigue, generalized weakness or body ache, dizziness, etc.

Make sure that you select an appropriate patient so that you can meet all the requirements of the assignment. This write-up should be 2-6 pages (excluding title page, reference page and templates).

This assignment is designed to promote the development of the following: AACN Essentials (2022): Domains 1, 2, 4, 6, and 9 and NONPF NP Core and Population-Focused Competencies (2012;2017): Scientific Foundational, Practice Inquiry, Technology and Information Literacy, and Independent Practice.

Case Write-up Outline

Following the format of: https://meded.ucsd.edu/clinicalmed/write.htm.

Subjective:

Chief Complaint: This should be in quotes: “I’ve had a cough and sore throat for 2 days.”

History of Present Illness: One of the most important parts of the assessment. Check the list of important questions to ask (OLD CARTS or PQRST). As you become more proficient in physical exam and lab testing, the HPI does not decrease in importance – your ability to use it in diagnostic reasoning just increases. 

Past Medical History: Past or present illness. Be careful with “blindly” copying history from a prior clinical note.

Past Hospitalizations: Past hospitalizations with reason for admit, duration of stay, and rough dates

Past Surgical History: Past surgeries and rough dates when possible.

Medications: List name, dose, frequency and indication (why are they taking it?) Do NOT omit PRN medications and how often the medications are taken. This is one way to check whether you’ve put all important information in your patient history.  If a patient is taking Metformin and there’s no related information on the history and/or diagnosis list, something is missing.

Allergies: Medications, Food allergies when applicable. Specify what type of reaction next to the allergy if known by the person you are collecting history from (E.g., Penicillin-rash)

Social History: This includes several factors: alcohol use, cigarette use, sexual history, work history are a few examples. Include health promotion information such as exercise and immunizations. Immunizations are important – we want to know the date of an adult patient’s last tetanus immunization. Be specific, don’t just say UTD. For pediatrics: list dates for all immunizations.

Other pediatric specifics: list who all lives in home with patient, how many siblings with ages next to them, type of home, any pets inside/outside home & what type of pet, any smoking in home, any guns in home; if young child – are they in daycare or if babysitter or family member or parent stay home with child, are they in school & what grade and what type of grades does the child make, list any extracurricular activities, any problems with school or teacher, any recent social or home changes. If they are pre-teen and older – add alcohol use, smoking, sexual history, work history, etc.

Family History: It is generally appropriate to go back at least two generations. State family member (mom/dad/maternal grandparents/paternal grandparents/siblings/etc.), their age & if they’re alive (if they are deceased, write deceased), write any conditions or illnesses next to each person, write unknown if history not known

Obstetrical History: When appropriate, document number of pregnancies and other relevant information.

Birth History: applicable for pediatric write ups especially for young pediatric patients

Review of Symptoms (ROS): Should be extensive and include every system. Always address growth and development in pediatric patients. Nutrition should be addressed, especially in pediatric patients. In childbearing women (any teen or female who have reached menarche), make sure to document date of last menstrual period (LMP) and methods of contraceptive use on every visit on any woman capable of becoming pregnant (having menses and has not had a tubal ligation/hysterectomy).

Every visit – If you order such a medication without documenting the above information, we have to assume that the patient could be pregnant (as would any lawyer in a lawsuit).  For a young teen you can put “not sexually active” (but make sure you have asked).  This is sometimes tricky with teens being seen for general health problems but so very important.  If in any doubt, ask the parent to step out for a moment so that you can talk to the teen alone. Data should be systemically presented.

Objective:

Vital signs: (BMI should be included on every visit)

Physical examination – This is head to toe detailed and thoroughly describe findings within ALL systems. Do not put within normal limits (WNL). Make sure to describe all findings. Findings should be displayed in a systematic fashion.

Any laboratory findings, diagnostic imaging available at the time of the visit should be documented. Do not include testing that was ordered during the visit but results were not available.

TIP:

Make sure to proper distinguish between subjective and objective data. Subjective data, as the name suggests, is the information you gather by interviewing the patient, family, or significant other. This will include data from chief complaint, social/family history, and Review of System (ROS). Objective data will include those information or data you elicited through physical examination, vital signs and/or diagnostic test results.

Note that statement such as “Denies chest pain, sob, dysuria, vaginal bleeding, diarrhea, etc.” should be in the subjective section (ROS) of your note, and not in PE section.  Do not write “Alert and oriented; no tenderness; no erythema; breath sounds clear; no spine curvature” under ROS or subjective section. These are objective findings. You elicited these data through your physical examination of the patient.

Assessment:

In future semesters, you will begin to form your differential diagnoses and presumptive diagnoses. This is documented under the assessment. Your assessment should always be supported by findings in your history and physical exam. For this write up, you will list any diagnoses made by your preceptor.

You will complete a pathophysiology template for each diagnosis made by your preceptor. You should use resources from the previous courses and other current evidence-based sources to complete your pathophysiology templates. Cite appropriately. The pathophysiology template can be located in Appendix A.

Plan:

In future semesters, you will order medications, labs tests, referrals, conduct patient teaching and determine when the patient needs to follow-up. For this write up assignment, you will present the plan created by your preceptor. Please be sure this information is organized under each diagnosis; keeping it organized helps the write up flow well to where the reader is able to get a clear picture of everything you did during the patient encounter.

You will create a medication card for each medication your preceptor ordered/refilled/continued. You should use resources from previous courses and current evidence-based sources to complete your medication cards. Cite appropriately. The medication card template can be located in Appendix B.

Templates will require APA-formatted in-text citations and sources should be included on an APA reference list.

Addendum

***Remember to add an additional note at the end of the write-up if you realized anything was missing from the encounter that should have been done or ordered. Put it at the end of your write up and label it: Addendum ***

MSN History and Physical Examination Case Write-Up Rubric

CriteriaExceeds ExpectationsMeets ExpectationsBelow ExpectationsNo EffortChief Complaint(CC)3 Points Includes CC includes the reason for visit, is appropriate for the type of write-up AND is in the patient/family’s own words.2 Points Includes CC that includes the reason for visit, is appropriate for the type of write-up but is not in the patient/family’s own words 1 Point CC is not appropriate for the type of write-up AND is not in the patient/family’s own words 0 Points Not includedHistory of Present Illness(HPI)10 pointsProvides a comprehensive HPI that includes all the pertinent information and excludes irrelevant information. HPI is focused and detailed. Does not include any objective data7 pointsProvides a HPI that includes pertinent information but misses 1 -2 key components and/or includes information that is irrelevant to the patient visit. HPI is somewhat focused. Does not include objective data.4 pointsProvides a superficial HPI that misses 3 or more key components and/or does not include all pertinent information, includes irrelevant information OR includes objective data0 PointsNot includedMedications3 PointsDocuments a comprehensivemedication list that includes drug name (brand and generic), dosage, route, frequency and indication. Allergies are documented and includes reaction. Includes NDKA, if applicable.2 PointsDocumentation includes medication list but omits 1-2 details. Allergies are documented but does not include reaction.1 PointDocumentation includes medications but omits 3 or more details. Allergies are not documented0 PointsNot includedPertinent History10 PointsProvides comprehensive past medical history, surgical, family, social, obstetrical history, and birth history (when applicable). History is consistent with other documentation. Includes immunization information 7 PointsProvides a history but history is superficialOmits 2-3 necessary details 4 PointsProvides a history but history of superficial and omits 4 or more details 0 PointsNot includedReview of Systems10 Points Complete ROS that addresses each physical system ROS is completed with a clear narrative. Do not write within normal limit or other variations. If documented abnormalities, states what is considered ‘normal’ Does not include any objective data7 Points Incomplete ROS that misses 2-3 components4 Points Incomplete ROS that misses 3 or more components Includes objective data0 Points No ROS attemptedObjective Data20 PointsDocuments vital signs with documented BMI Documents physical examination:Each system addressed completely and includes pertinent positive and pertinent negative findings. Documents labs, diagnostic tests that are available for that visit. Does not include any subjective data14 Points Documents vital signs but is missing BMI Documents an incomplete physical examination:missing 3 or less components and/or missing up to 3 pertinent positives/negatives Documents labs, diagnostic tests that are available for that visit.8 Points Does not document vital signs Documents an incomplete physical examination:missing 4 or more of the components and/ or missing 4 or more pertinent positives/negatives Fails to document labs, diagnostic tests that are available for that visit. Includes subjective data  0 PointsNot includedAssessment20 PointsLists all diagnoses made by the preceptor Includes a pathophysiology template for medical diagnosis made by the preceptor Each pathophysiology template is fully completed and contains accurate and current information Template is supported by evidence-based sources  14 PointsLists all diagnoses made by the preceptor Pathophysiology template present for each medical diagnosis but missing information OR information is inaccurate Template is not supported by evidence-based sources8 PointsFails to list all diagnoses or diagnosis is not related to patient based on documented history and physical examination Pathophysiology templates present but do not address all diagnoses AND is missing information and/or information is inaccurate and/or template is not supported by evidence-based sources 0 PointsNot effortPlan14 PointsProvides a plan made by the preceptor. Includes a medication card/ template for each medication the patient is currently taking and any medication ordered by the preceptor. Each medication card/template is fully completed and contains accurate and current information Template is supported by evidence-based sources 9 PointsProvides a plan made by the preceptor Includes a medication card/template for each medication the patient is currently taking and any medication ordered by the preceptor but missing information OR information is inaccurate Template is not supported by evidence-based sources4 PointsProvides a plan that is not relevant to the patient’s visit Medication card/template present but does not address all medications AND missing information and/or information is inaccurate and/or template is not supported by evidence-based sources0 PointsNot included or inappropriate to patient visitFormatting/APA10 Points No errors in  grammar and spelling . No errors in APA format Write-up is in proper format and adheres to the appropriate page limits.7 Points1-2 spelling or grammar errorsOR1-2 APA errors 4 Points4 errors in spelling or grammarOR4 APA errorsORWrite-up is not in proper formatORWrite up does not adhere to the appropriate page limits 0 Points5 or more errors in spelling or grammarOR5 or more APA errorsANDWrite up does not adhere to the appropriate page limits 

MSN History and Physical Examination Case Write Up Assignment Example Solution

Subjective:

Chief Complaint: “I don’t enjoy anything anymore and always feel down.”

History of Present Illness: Ms M, a 38-year-old woman, has deteriorated mood over the past six months. Initially, she experienced a mild decrease in her energy levels, attributed to work-related stress and her recent divorce. However, this decline was followed by an evident loss of interest and enjoyment in activities that previously brought her pleasure, such as reading, hiking, and socializing with friends.

Her sleep patterns have become disrupted, and she frequently wakes up multiple times during the night with persistent feelings of despair and regret from the past. This disrupted sleep has contributed significantly to her daily exhaustion, causing significant fatigue.

Additionally, she mentions a decrease in appetite, leading to unintentional weight loss of around 10 pounds over the past three months. She struggles with concentration at work and often has to read documents multiple times for comprehension, which was not previously an issue. She denies any thoughts or intentions of self-harm or suicide but admits to moments where she wishes she could “disappear.”

Apart from her divorce approximately eight months ago, there have not been any noteworthy changes or stressors in her life. She has never experienced these emotions before and is worried about her ability to function normally since she has begun isolating herself from loved ones due to her low mood. 

Past Medical History: Ms M was diagnosed with Polycystic Ovary Syndrome in her mid-20s due to irregular menstrual cycles and signs of hirsutism. At 32, she experienced mild gestational diabetes during pregnancy, which resolved after giving birth. There is no record of any other chronic conditions. During her early 30s, Ms.M reported experiencing frequent headaches, which were considered tension-type, but it has become less frequent over time.

Past Hospitalizations: At 24, she was hospitalized due to a ruptured ovarian cyst associated with her polycystic ovary syndrome. She received two-day treatment to alleviate pain and monitor for potential complications.

Past Surgical History:

2014, laparoscopic cholecystectomy for recurrent gall stones.

2015, caesarian section due to breech presentation.

Medications:

Metformin 500mg Orally B.D

Ibuprofen 400mg as needed to relieve headaches and menstrual pain, about 2-3 times per month. Ongoing use of prenatal vitamins once daily since her pregnancy for comprehensive health support.

Allergies: Penicillin caused a rash and swelling when she was a child. Shellfish – causes itching and hives.

Social History:  

Work: She works as a financial analyst and sometimes finds her job difficult.

Alcohol use: Enjoys a glass of wine weekly.

Cigarette smoking: She smoked briefly in her early twenties before quitting 13 years ago.

Sexual history: Divorced heterosexual woman who utilizes barrier contraception.

Previously engaged in hiking; now less so due to mood.

Immunization: The last tetanus shot was in 2017; the flu vaccine was administered the previous year.

Family History:

• Mother (65), hypertensive and diabetic.
• Father (died at 70): Major depressive disorder, coronary artery disease.
• Brother (42) has asthma.
• Maternal Grandparents: The grandfather had Alzheimer’s, while the grandmother had osteoporosis.
• Paternal Grandparents: Grandfather was diagnosed with prostate cancer, and Grandmother was diagnosed with rheumatoid arthritis.

Obstetrical history includes two pregnancies. First, she miscarried. A healthy child was born due to a second pregnancy at 32, delivered via cesarean due to breech position.

Review of Symptoms (ROS):

·   General: Reports unintentional weight loss fatigue. Denies fever or chills.

·   HEENT: Reports an occasional headache but no head trauma or dizziness

Eyes: Reports that her vision is intact

Ears: No complaints of any hearing problems.

Nose: She reports not having nasal congestion or a runny nose; her sense of smell is intact.

Throat: no mention of difficulty when swallowing.

·   Neurological: Decreased concentration; occasional mild headaches.

·   Cardiovascular: Denies chest pain or palpitations.

·   Respiratory: No shortness of breath, cough, or wheezing.

·   Gastrointestinal: Reduced appetite; denies nausea, vomiting, diarrhea.

·   Genitourinary: Regular menses; denies dysuria or hematuria.

·   Musculoskeletal: Denies joint pain or muscle weakness.

·   Integumentary: Denies rashes or changes in moles.

·   Lymphatic system: does not have any swellings in her nodes

·   Endocrine: Can tolerate both cold and hot weather usually.

·   Psychiatric: Chronic low mood, anhedonia, and feelings of hopelessness. Denies hallucinations or suicidal ideation.

Objective:

Vital signs: Blood Pressure: 120/78 mmHg Heart Rate: 72 bpm Respiratory Rate: 16 breaths/min Temperature: 98.6°F (37°C) weight 69 kg height 169 cm BMI: 24.2

Physical examination

·   General: Fair general state, alert, oriented to person, place, and time. Not in any apparent distress. She is well groomed and appears her stated age.

·   Head: Normocephalic, atraumatic, with her hair evenly distributed.

·   Eyes: Pupils equal, round, reactive to light and accommodation (PERRLA). Conjunctivae clear.

·   Ears: Tympanic membranes are pearly grey with a good cone of light visualization.

·   Nose: The mucosa is pink, and there is no nasal discharge.

·   Mouth: Moist mucous membrane, good dentition, and oral hygiene. No oropharyngeal erythema.

·   Neck: Trachea midline. No lymphadenopathy or thyromegaly.

·   Cardiovascular: Regular rate and rhythm. On auscultation S1 and S2 noted and no murmurs.

·   Respiratory: Clear to auscultation bilaterally. No wheezing, rhonchi, or rales.

·   Gastrointestinal: Abdomen is warm to the touch, soft, non-distended, non-tender. Bowel sounds active in all quadrants.

·   Musculoskeletal: Full range of motion in all extremities. No joint swelling or tenderness.

·   Neurological: Cranial nerves II-XII intact. Sensation was intact to light touch.

·   Skin: Warm and dry to the touch. No rashes, lesions, or suspicious nevi.

Laboratory Findings:

Thyroid function tests:

TSH: 3.0 mIU/L (Reference range: 0.4 – 4.0 mIU/L)

Free T4: 1.2 ng/dL (Reference range: 0.8 – 2.0 ng/dL)

Complete Blood Count (CBC):

Hemoglobin: 14 g/dL (Reference range for females: 12-16 g/dL)

White Blood Cell Count: 6,000 /µL (Reference range: 4,000-11,000 /µL)

Diagnostic Imaging:

No imaging was done during the visit.

Assessment:

Diagnosis: Major Depressive Disorder

Ms. M. exhibits signs of major depressive disorder, such as chronic melancholy, loss of interest in everyday activities, chronic exhaustion, and irregular sleep patterns. The clinical manifestations of MDD, which are brought on by genetic, physiological, environmental, and psychological factors, closely match these symptoms.

MDD is thought to develop and progress due to the disruption in neurotransmitters such as serotonin, norepinephrine, and dopamine. The extensive symptoms seen in those with this disease can be caused by a physiological imbalance resulting in the dysregulation of mood control mechanisms.

According to the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition criteria, five specific symptoms must be present to diagnose MDD, including a substantial low mood or anhedonia that significantly impairs social or occupational functioning. In Ms. M’s case, her detailed history suggests alignment with several of these criteria.

It is crucial to conduct further assessment to ensure that she does not have an account of manic or hypomanic episodes, which could indicate a different mood disorder instead of MDD. A thorough understanding of the pathophysiology and evident manifestations of this illness in patients like Ms. M can assist clinicians in developing an effective and individualized treatment plan (de Menezes Galvão et al., 2021; Bains & Abdijadid, 2022).

Differential diagnosis

Generalized Anxiety Disorder (GAD)

The hallmark of generalized anxiety disorder is constant, uncontrollable concern that affects different facets of life, including relationships, employment, and health. This excessive worrying can last for more than six months. Physical symptoms associated with GAD may resemble depression, including fatigue, restlessness, muscle tension, and sleep disturbances (Newman et al., 2022).

Ms. M exhibits signs of potential GAD based on her reported fatigue, sleep problems, and concerns related to her recent divorce and job situation. It is important to note that the primary symptom distinguishing GAD from Major Depressive Disorder is the presence of anxiety and chronic worry in GAD compared to the pervasive depressed mood observed in MDD.

Moreover, GAD does not typically include profound anhedonia—the loss of interest or pleasure in most activities— which further sets it apart from MDD.In summary, Ms.M’s presentation suggests possible Generalized Anxiety Disorder rather than Major Depressive Disorder due to the absence of a predominant depressive mood characteristic.

Dysthymia

Dysthymia, also referred to as Persistent Depressive Disorder, is characterized by a chronic manifestation of depression that lasts for at least two years (Quagliato et al., 2023). Periods of major depressive episodes can occur intermittently within this duration. It would be required to take dysthymia into account if Ms. M had been enduring persistent depressed symptoms for more than two years.

Although both Major Depressive Disorder and dysthymia entail depressive symptoms, it is essential to remember that their primary distinction is the length of time that these symptoms last (Quagliato et al., 2023). Dysthymia is associated with its enduring and persistent nature, lasting at least two years, whereas MDD may present itself through shorter yet more intense episodes.

Plan:

Major Depressive Disorder (MDD), Single Episode, Moderate:

1. Pharmacotherapy: Commence treatment with a daily oral dose of 50mg of Sertraline to manage depressive symptoms. Evaluate the individual’s progress after four weeks and contemplate modifying the dosage per their therapeutic response and any adverse reactions encountered. Discuss potential side effects such as nausea, dizziness, disruptions to sleep patterns, and any indications suggesting serotonin syndrome.

2. Psychotherapy: Consult with a licensed therapist for Cognitive Behavioral Therapy (CBT) sessions, initially weekly for eight sessions, then re-evaluate the necessity for ongoing therapy based on response.

3. Lifestyle Modifications:

Encourage the re-engagement of previously enjoyed leisure activities such as hiking.

Recommend consistent engagement in physical activity, aiming for a minimum of 30 minutes per session, at least five days per week.

Guide practicing good sleep hygiene habits to enhance the quality of sleep.

4. Follow-up: A consultation in 4 weeks is recommended to review the efficacy and tolerability of the prescription medicine and the patient’s mood and overall well-being. If no change or symptoms worsen, it may be time to consult a psychiatrist.

5. Safety Assessment: Although Ms M denied having suicidal thoughts, it is crucial to watch for any emerging suicidal or self-harming thoughts, particularly in the early stages of treatment. She needs to stay around people to avoid suicidal thinking. They can also dial 911 or go to the nearest emergency room.

6. Educate: Explain the typical delay in experiencing therapeutic benefits from antidepressants, which typically occurs within 2 to 4 weeks. Emphasize the significance of gradually tapering off medication instead of abruptly discontinuing it to avoid potential withdrawal symptoms. Encourage consulting a healthcare professional if there is an intention to stop treatment.

Addendum

Upon further reflection on Ms M’s appointment, it is worth considering a few areas for improvement:

1.     Comprehensive Exploration of Psychosocial Stressors: To better understand the onset and contributing factors of her depressive episode, it would have been helpful to delve deeper into any additional psychosocial stressors or triggers beyond her job and recent divorce.

2.     Screening for Substance Use: While alcohol use was discussed, future evaluations should include a more detailed examination of substance use history, including potential illicit drug use or misuse of prescription medications. This is important as substance use can contribute to or exacerbate depressive symptoms.

3.     Analysis of Previous Episodes: Given the diagnosis of Major Depressive Disorder, it would be beneficial to explore any previous instances where Ms. M experienced depressive episodes in her younger years or following significant life events. Understanding this history could assist in predicting treatment responsiveness and providing insight into the course she may experience moving forward.

Appendix A

Disease : Major Depressive Disorder

Solution: