| Course | NU676 PMHNP Diagnosis and Management Across the Lifespan Clinical II |
|---|---|
| Unit | Unit 9 |
| Paper type | Serial visit note set |
| Length | About 850 words, 6 pages double-spaced |
| Format | APA 7 student paper |
| School | Purdue University Global |
| Program | MSN |
| Updated | September 2026 |
Free sample paper for NU676 Unit 9
Four Visits, One Blood Pressure Rise: A Serial Visit Note Set Following Duloxetine for Depression and Chronic Back Pain in a 47-Year-Old Upholsterer
[Student Name]
Purdue University Global
NU676: PMHNP Diagnosis and Management Across the Lifespan Clinical II
Unit 9 Serial Visit Note Set
[Instructor Name]
[Date]
The patient is composite; doses, scores and readings are bracketed.
Visit 1, Week 0: Starting Point
Mr. [U.], [47], upholsterer, major depressive episode for [four] months and chronic low back pain for [six] years, worse since a lifting injury in the spring. MADRS [30], moderate depression; the MADRS was designed to be sensitive to change during treatment (Montgomery & Åsberg, 1979). Back pain [7] of 10 on most days. Blood pressure [128/82], heart rate [74]. Taking ibuprofen most days.
Decision: duloxetine [30] mg daily for one week, then [60] mg. Rationale: it treats depression and has randomized trial evidence in chronic low back pain, where it reduced average pain and improved function compared with placebo, although more patients stopped for side effects (Skljarevski et al., 2010). Reduce ibuprofen given the risk of bleeding with combined use. Next visit in [three] weeks.
Visit 2, Week 3: Since Visit 1
Changed: nausea for the first [five] days, now resolved. Sleep slightly better. MADRS [24]. Pain [6] of 10. Ibuprofen down to [two] days a week. Blood pressure [130/82].
Read: early improvement in mood and pain; side effects settling.
Decision: continue [60] mg. Next visit in [three] weeks.
Visit 3, Week 6: Since Visit 2
Changed: mood and pain continue to improve. MADRS [17]. Pain [4] of 10; he has returned to full shifts. New: blood pressure [146/94], confirmed at [144/92] after rest; home readings over the past week average [142/90]. Heart rate [82]. No headache or chest pain.
Read: a meaningful rise in blood pressure since starting duloxetine. Serotonin and norepinephrine reuptake inhibitors can raise blood pressure. In pooled trial data, duloxetine had modest effects on heart rate and blood pressure, comparable to first-line antidepressants, with sustained elevations uncommon (Thase et al., 2005). His rise is larger than average and needs a response.
The drug is helping both his mood and his back, so the question at this visit is how to manage the blood pressure, not whether to abandon the treatment.
Decision: continue duloxetine [60] mg; do not increase further. Refer to primary care for blood pressure assessment and treatment; review salt intake, alcohol and his over-the-counter decongestant, which he has been using for a cold. Stop the decongestant. Home readings twice daily. Next visit in [two] weeks rather than four.
Visit 4, Week 10: Since Visit 3
Changed: decongestant stopped; primary care started amlodipine [5] mg at week [seven]. Home blood pressure now averages [128/80]; clinic reading [130/82]. MADRS [11], mild. Pain [3] of 10. Ibuprofen rarely.
Read: blood pressure controlled; depression approaching remission; pain much improved.
Decision: continue duloxetine [60] mg. Aim for remission, MADRS below about [10], by week [16]; if not reached, discuss whether to increase the dose, weighing blood pressure. Continue home readings weekly. Next visit in [four] weeks.
Safety Checks Carried Through the Series
Three checks recurred at every visit. Suicidal thoughts were asked about directly at each visit and were absent throughout, which matters in the early weeks of antidepressant treatment. Bleeding risk was reviewed because he had been taking ibuprofen most days when duloxetine started; combining a serotonergic antidepressant with a nonsteroidal anti-inflammatory raises the risk of gastrointestinal bleeding, which is why ibuprofen was cut back at the first visit and was rarely needed by the fourth. Liver health was considered because he drinks [three to four] beers on weekends; he was advised to keep alcohol modest, and liver tests from his primary care visit at week [seven] were normal. Recording these checks in each note, even when nothing had changed, means the next clinician can see that they were done rather than assume it.
His Account of the Ten Weeks
At the fourth visit Mr. [U.] was asked what had made the difference. He said the pain had been the first thing to ease, around the third week, and that once he could sleep through the night without his back waking him, his mood "started to catch up." He had been alarmed by the blood pressure reading and had expected to be told to stop the medicine, and he was relieved that the plan dealt with the pressure instead. He said the cold medicine had never occurred to him as a factor, and he has since checked the labels of everything in his cabinet. His account matches the order of change in the scores: pain first, then sleep, then mood.
What the Series Shows
1. Mood: MADRS [30], [24], [17], [11].
2. Pain: [7], [6], [4], [3] out of 10.
3. Blood pressure: [128/82], [130/82], [146/94], [130/82] after treatment.
4. Function: back to full shifts by week six.
The blood pressure rise at week six could have ended an effective treatment. Instead, the series shows it being checked, partly explained by a decongestant, and treated, while the benefits continued.
References
Montgomery, S. A., & Åsberg, M. (1979). A new depression scale designed to be sensitive to change. British Journal of Psychiatry, 134(4), 382-389. https://doi.org/10.1192/bjp.134.4.382
Skljarevski, V., Desaiah, D., Liu-Seifert, H., Zhang, Q., Chappell, A. S., Detke, M. J., Iyengar, S., Atkinson, J. H., & Backonja, M. (2010). Efficacy and safety of duloxetine in patients with chronic low back pain. Spine, 35(13), E578-E585. https://doi.org/10.1097/BRS.0b013e3181d3cef6
Thase, M. E., Tran, P. V., Wiltse, C., Pangallo, B. A., Mallinckrodt, C., & Detke, M. J. (2005). Cardiovascular profile of duloxetine, a dual reuptake inhibitor of serotonin and norepinephrine. Journal of Clinical Psychopharmacology, 25(2), 132-140. https://doi.org/10.1097/01.jcp.0000155815.44338.95
The Purdue Global NU676 Unit 9 instructions
For Unit 9 you document a series of follow-up visits for one patient, showing how treatment evolved. Each note in the set should open with what changed since the last visit, report the same measures each time, state how the findings were read and give the decision with its reason. Sets of three to five notes over two to three months are typical. Instructors reward sets in which a reader can follow the patient's course without rereading earlier notes, and in which an unexpected finding, such as a side effect, is handled with a clear rationale rather than an automatic stop. A summary of measures across all visits helps the reader see the pattern at a glance.
Inside the NU676 Unit 9 example
Visit one records his MADRS of 30, pain score, blood pressure and ibuprofen use, and starts duloxetine with the back pain trial and the MADRS source cited. Visit two records early nausea, improvement and reduced ibuprofen. Visit three records continued gains and the blood pressure rise, cites the pooled cardiovascular data for duloxetine, and a highlighted sentence frames the decision. The decongestant is stopped and primary care treats the pressure. Visit four shows control and a MADRS of 11. A section describes three safety checks repeated at every visit, his account of the ten weeks follows, and a four-line summary tracks mood, pain, blood pressure and function.
Reading the NU676 Unit 9 grading rubric
Serial note sets are generally graded on continuity, consistent measurement, clinical reasoning at each visit, safety monitoring and a summary of the course. Continuity earns full marks when each note starts from the previous one. Consistent measurement rewards the same scales and vitals at every visit. Reasoning is judged at the visit where something unexpected happened; the decision to keep an effective drug while treating a side effect must be explained. Safety credit goes to recurring checks such as suicidal thinking, bleeding risk and alcohol. The summary row looks for a compact view of all measures across the visits that shows the direction of each.
NU676 Unit 9 help from the desk
The most frequent weakness is notes that each restart the history, so the change is buried. Another is switching scales between visits, which makes comparison impossible. Students often stop a drug at the first abnormal vital sign without checking for other causes, such as a decongestant. Some sets forget to reduce an NSAID when starting a serotonergic antidepressant. Others record safety checks only at the first visit. And a set without a closing summary leaves the reader to reconstruct the course from four separate notes, which few busy clinicians will do before the next visit. Repeat the safety questions even when the answer is the same, and write the answer down each time.
Get an NU676 Unit 9 example written to your instructions
Serial note assignments usually specify how many visits and over what span, so include those details from NU676 Unit 9, the note template and the rubric. Returned within 24-48h and free the first time, the set follows a composite patient visit by visit, with a running tracker and each note answering the question the previous one raised. The paper above is an original model document written by our desk, not a submitted student paper and not an official Purdue University Global document.
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NU676 Unit 9 questions, answered
What is the MADRS?
The Montgomery-Asberg Depression Rating Scale, published by Stuart Montgomery and Marie Asberg in 1979, is a ten-item clinician-rated scale with a range of 0 to 60. It was designed to be sensitive to change with treatment, which suits serial notes. Cutoffs for response and remission vary between studies, so the note names the one it uses.
How much should each serial note repeat from the one before?
As little as possible. Each note should state the interval, answer the question the last visit raised and record current findings, pointing back rather than copying. Copied-forward text is a known documentation hazard because it can preserve findings that are no longer true. The tracker carries the history, so the notes can stay brief.
Why does the plan hold the dose when blood pressure rises?
Because a single elevated reading may not reflect his usual pressure, and cutting the dose risks losing an antidepressant response that is just emerging. Holding, rechecking and gathering home readings tests the finding before acting on it. If the readings had stayed high, the next note would have changed course, and the sample says so explicitly.
Where can I find a free NU676 Unit 9 sample paper?
The complete NU676 Unit 9 serial visit note set is shown here, with four notes, recurring safety checks, his account of the ten weeks and a summary of mood, pain, blood pressure and function, plus three references. A note set for your own patient can be drafted.
Why was duloxetine continued despite high blood pressure in NU676 Unit 9?
It was helping both his depression and his back pain. The rise was partly explained by a decongestant, which was stopped, and primary care started amlodipine; pooled data show duloxetine usually has modest effects on blood pressure.