Case Study Assignment

Guidelines with Scoring Rubric

Purpose

The purpose of this case study assignment is to

1) Analyze provided subjective and objective information to diagnose and develop a 

management plan for the case study patient.

2) Apply national diabetes guidelines to case study patient management plan.

3) Demonstrate mastery of SOAP note writing.

Course Outcomes

Through this assignment, the student will demonstrate the ability to:

1. Employ appropriate health promotion guidelines and disease prevention strategies in the 

management of mature and aging individuals and families. 

2. Formulate appropriate diagnoses and evidence-based plans of care for mature and aging 

individuals and families using subjective and objective data.

3. Incorporate unique patient cultural preferences, values, and health beliefs in the care of mature 

and aging individuals and families

4. Integrate theory and evidence based practice in the care of mature and aging individuals and 

their families

6. Conduct pharmacologic assessment addressing polypharmacy, drug interactions and other 

adverse events in the care of mature and aging individuals and their families.

7. Apply evidence-based screening tools to perform functional assessments with aging individuals 

and their families as appropriate.

Due Date: Sunday 11:59 p.m. MT at the end of Week 5

Total Points Possible: 200 points

PREPARING THE ASSIGNMENT 

The assignment is a paper which is to be written in APA format. This includes a title page and 

reference page.

Review the attached patient visit information. The patient has presented for an acute care visit. You 

are provided with the subjective and objective exam findings. As the provider, you are to diagnose 

and develop the management plan for this case study patient. 

Use the categories below to create section headings for your paper.

Introduction: briefly discuss the purpose of this paper.

Assessment: review the provided case study information.

Chamberlain College of Nursing NR601 

2

Identify the primary, secondary and differential diagnoses for the patient. Use the 601 SOAP note 

format as a guide to develop your diagnoses.

Each diagnosis will include the following information:

1. ICD 10 code.

2. A brief pathophysiology statement which his no longer that 2 sentences, paraphrased and 

includes common signs and symptoms of the diagnosis.

3. The patient’s pertinent positive and negative findings, including a brief 1-2 sentence 

statement which links the subjective and objective findings (including lab data and 

interpretation).

4. A rationale statement which summarizes why the diagnosis was chosen. 

5. Do not include quotes, paraphrase all scholarly information and provide an intext citation to 

your scholarly reference. Use the Reference Guidelines document for information on 

scholarly references. 

Plan (there are five (5) sections to the management plan)

1. Diagnostics. List all labs and diagnostic test you would like to order. Each test includes a 

rationale statement which includes the diagnosis for the test, the purpose of the test and 

how the test results will contribute to your management plan. Each rationale statement is 

cited. 

2. Medications: Each medication is listed in prescription format. Each prescribed and OTC 

medication is linked to a specific diagnosis and includes a paraphrased EBP rationale for 

prescribing. 

3. Education: section includes detailed education on all five (5) subcategories: diagnosis, each 

medication purpose and side effects, diet, personalized exercise recommendations and 

warning sign for diagnosis and medications if applicable. All education steps are linked to a 

diagnosis, paraphrased, and include a paraphrased EBP rationale. Review the NR601 

SOAP note guideline for more detailed information. 

4. Referrals: any recommended referrals are appropriate to the patient diagnosis and current 

condition, is linked to a specific diagnosis and includes a paraphrased EBP rationale for 

ordering 

5. Follow up: Follow up includes a specific time frame to return to PCP office for next 

scheduled appointment. Includes EBP rationale with in text citation.