NUR601 week 5 case study assignment paper
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.
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.
Medication costs: in this section students will research the costs of all prescribed monthly medications. Students may use Good Rx, Epocrates or another resource (can use local pharmacy websites) which provides medication costs. Students will list each medication, the monthly cost of the medication and the reference source. Students will calculate the monthly cost of the case study patient’s prescribed and OTC medications. Reflect on the monthly cost of the medications prescribed. Discuss if prescriptions were adjusted due to cost. Discuss if will you use medication pricing resources in future practice.
SOAP note: A focused SOAP note, written on a separate page, follows the assignment. The SOAP note is written following the provided SOAP note format.
· The subjective section is organized to follow the SOAP note format. The ROS is focused, only pertinent body systems are included.
· The objective section is maintained as written, no additional information is added.
· The assessment section includes only the diagnoses and ICD 10 codes. Diagnosed are labeled as primary, secondary or differential diagnoses. Rationale is not required.
· The plan includes 5 sections. Rationale is not required.
The assignment will be submitted through TurnItIn.
Category
Points
%
Description
Assessment
50
25
Each diagnosis, primary, secondary and differential includes the ICD10 codes in parentheses next to each diagnosis. A one to two sentence paraphrased pathophysiology statement explains the diagnosis. Include pertinent positive and negative findings to support your diagnoses from the history and physical exam which links this diagnosis to your patient. Each diagnoses must include an intext citation to a scholarly reference.
Evidence-Based Practice (EBP)
50
25
National guidelines, including the American Diabetes Association Standards and Medical Care in Diabetes-2017, are used as rationale to support the diagnosis and develop the management plan. Every diagnoses must include an intext citation to a scholarly reference. Each action step or order within all plan sections includes an intext citation to an appropriate reference as listed in the Reference Guidelines document.
Plan: diagnostics
10
5
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.
Plan: medications
10
5
Each prescribed and OTC medication is linked to a diagnosis, and includes a paraphrased EBP rationale and in text citation. Diagnosis is clearly stated in the rationale statement.
Plan: education
10
5
All education steps are linked to a diagnosis, paraphrased, and include an EBP rationale. Section includes detailed education on diagnosis, medications, diet, exercise and warning signs.
Plan: Referrals
10
5
All recommended referrals are appropriate for the patient diagnosis and condition, is linked to a specific diagnosis and includes a paraphrased EBP rationale for ordering
Plan: Follow up
10
5
Follow up includes a specific time frame to return to PCP office for next scheduled appointment.
Medication costs
10
5
All prescribed medications costs are calculated to evaluate the monthly medication cost for the patient.
SOAP note
20
10
A SOAP note, written in a separate page, follows the assignment. The SOAP note is written following the provided SOAP note format.
Grammar, Syntax, APA
10
5
APA format, grammar, spelling, and/or punctuation are accurate, or with zero to one errors.
Organization
10
5
Total
200
100
A quality assignment will meet or exceed all of the above requirements.
Grading Rubric
Criterion
Exceptional
Outstanding or highest level of performance
Exceeds
Very good or high level of performance
Meets
Satisfactory level of performance
Needs Improvement
Poor or failing level of performance
Developing
Unsatisfactory level of performance
Content
Possible Points = 180
Assessment
50 Points
44 Points
41 Points
20 Points
0 Points
All three diagnostic categories are present.
Each diagnosis, primary, secondary and differential, includes the ICD10 codes in parentheses next to each diagnosis.
Each diagnosis includes a one to two sentence paraphrased pathophysiology statement explains the diagnosis and a rationale statement. The rationale statement includes pertinent positive and negative subjective and objective findings from the history and physical exam which links this diagnosis to your patient. All lab results are interpreted within the rationale statement.
All three diagnostic categories are present.
Each diagnosis, primary, secondary and differential includes the ICD10 codes in parentheses next to each diagnosis.
Each diagnosis includes a one to two sentence paraphrased pathophysiology statement explains the diagnosis and a rationale statement.
The rationale statement includes pertinent positive and negative subjective and objective findings from the history and physical exam which links this diagnosis to your patient.
All lab results are not interpreted within the rationale statement.
All three diagnostic categories are present.
Each diagnosis, primary, secondary and differential includes the ICD10 codes in parentheses next to each diagnosis.
The pathophysiology statement is not present or not paraphrased,
The rationale statement includes pertinent positive and negative subjective and objective findings from the history and physical exam which links this diagnosis to your patient.
All lab results are not interpreted within the rationale statement.
All three diagnostic categories are not developed: a primary, secondary or differential diagnosis category is not included.
Diagnoses are not present.
Evidence-Based Practice
50 Points
44 Points
41 Points
20 Points
0 Points
National guidelines, including the American Diabetes Association Standards and Medical Care in Diabetes-2017, are used to support the primary diagnosis and develop the plan.
Every diagnosis rationale must include an intext citation to a scholarly reference. Each action step or order within all plan sections includes an intext citation to an appropriate reference as listed in the Reference Guidelines document. All cited information is paraphrased, no quotes included.
National guidelines, including the American Diabetes Association Standards and Medical Care in Diabetes-2017, are used to support the primary diagnosis and develop the plan.
Every diagnosis rationale must include an intext citation to a scholarly reference.
One or two steps or orders within all plan sections may be missing an intext citation to an appropriate reference as listed in the Reference Guidelines document. All cited information is paraphrased, no quotes included.
National guidelines, including the American Diabetes Association Standards and Medical Care in Diabetes-2017, are used to support the primary diagnosis and develop the plan.
Every diagnosis rationale does not include an intext citation to an appropriate reference as listed in the Reference Guidelines document.
One or two steps or orders within all plan sections may be missing an intext citation to an appropriate reference as listed in the Reference Guidelines document. All cited information is paraphrased, no quotes included.
The American Diabetes Association Standards and Medical Care in Diabetes-2017 is not used as reference.
Every diagnosis rationale does not include an intext citation to an appropriate reference as listed in the Reference Guidelines document.
Two steps or orders within any plan section are be missing an intext citation to an appropriate reference as listed in the Reference Guidelines document.
Scholarly information includes quotations.
National guidelines, including the American Diabetes Association Standards and Medical Care in Diabetes-2017 are not used as references.
10 Points
9 Points
8 Points
4 Points
0 Points
Plan: Diagnostics
All ordered diagnostics tests are linked to a diagnosis and include a paraphrased EBP rationale.
All ordered diagnostics tests include an EBP rationale.
A diagnosis is not included within the rationale statement.
All ordered diagnostics tests are linked to a diagnosis;
EBP rationale with in text citation is missing;
OR
Rationale is a quotation.
Diagnostic tests include an intext citation to a non-scholarly internet or application source.
Diagnostic tests are not included
OR
Diagnostic tests do not include an intext citation.
10 Points
9 Points
8 Points
4 Points
0 Points
Plan: Medications
Each prescribed and OTC medication is linked to a diagnosis, and include a paraphrased rationale EBP rationale and in text citation. Diagnosis is clearly stated in the rationale statement.
All prescribed and OTC medication include a paraphrased EBP rationale and in text citation. The diagnosis is not clearly listed within the rationale statement.
Each prescribed and OTC medication is linked to a specific diagnosis. The diagnosis is clearly listed within the rationale statement. An EBP rationale is not included
OR
Rationale is a quotation.
Prescribed and OTC medications are listed.
Not every medication is linked to a diagnosis, and include a paraphrased rationale EBP rationale and in text citation.
Prescribed and OTC medications are not included in the case study.
10 Points
9 Points
8 Points
4 Points
0 Points
Plan: Education
All education steps linked to a diagnosis, paraphrased, and include an EBP rationale. Section includes personalized detailed education on diagnosis, medications, diet, exercise and warning signs.
All education steps are linked to a diagnosis, paraphrased and include an EBP rationale. One or 2 educational areas are not detailed or personalized to the patient.
All education steps are linked to a diagnosis and includes an EBP rationale.
OR
EBP rationale
is a quotation.
OR
Three (3) or more education areas do not include personalized detailed information.
Any education step is not linked to a diagnosis, paraphrased or an EBP rational is not provided.
Education section is not present.
10 Points
9 Points
8 Points
4 Points
0 Points
Plan: Referral
All recommended referrals are appropriate for the patient diagnosis and condition, is linked to a specific diagnosis and includes a paraphrased EBP rationale for ordering.
Some recommended referrals are appropriate for the patient diagnosis and condition, is linked to a specific diagnosis and includes a paraphrased EBP rationale for ordering.
All recommended referrals are appropriate for the patient diagnosis and condition, includes a paraphrased EBP rationale for ordering, specific diagnosis is not stated for every referral.
OR
EBP rationale
is a quotation.
Some recommended referrals are appropriate for the patient diagnosis and condition
Does not include a paraphrased EBP rationale for ordering.
Referral section is not present.
10 Points
9 Points
8 Points
4 Points
0 Points
Plan: Follow Up
Follow up includes a specific time frame to return to PCP office. Includes EBP rationale with in text citation.
Follow up is included in the plan but a specific time is not included (a range is included). Includes EBP rationale with in text citation.
Follow up is included in the plan but a specific time is not included.
Follow up is included in the plan, recommended follow up visit time frame is not EBP.
Follow up section not present.
20 Points
18 Points
16 Points
8 Points
0 Points
SOAP note
SOAP note included at end of assignment before reference page.
SOAP note includes all elements and is formatted exactly as described in the SOAP note guidelines document. Rationales are not included.
SOAP note included at end of assignment before reference page.
SOAP note includes all elements as listed in the SOAP note but not exactly as formatted in guidelines document.
Rationales are not included.
SOAP note included at end of assignment before the reference page.
SOAP note is formatted exactly as listed in the SOAP note guidelines document but is missing provided subjective or objective information.
SOAP note included, but not located at end of assignment before the reference page.
OR
SOAP note is not formatted exactly as shown in the SOAP note guidelines document and missing provided subjective or objective information.
Rationales are included.
SOAP note not included in assignment.
10 Points
9 Points
8 Points
4 Points
0 Points
Medication costs
Monthly medication costs are calculated.
All medications including OTCs are included.
Medication cost citation is included. Summary/reflection statement is included.
Monthly medication costs are calculated.
All medications including OTCs are included.
Medication cost reference is not included. Summary/reflection statement is included.
Monthly medication costs are calculated.
All medications including OTCs are included.
Summary/reflection statement is not included.
Monthly medication costs are calculated.
Summary statement/reflection is included.
OTCs are not included in monthly medication calculations.
Medication costs not calculated.
Content Subtotal
_____of 180 points
Format
Possible Points = 20
Grammar, Syntax, APA
10 Points
9 Points
8 Points
4 Points
0 Points
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 ten or greater errors in APA format, grammar, spelling, and/or punctuation.
Organization
10 Points
9 Points
8 Points
4 Points
0 Points
Paper is developed in a logical, meaningful, and understandable sequence using categories in instructions as section headings
SOAP note presents case study findings in a logical, meaningful, and understandable sequence following provided format.
Assignment contains all elements but may not be written following provided format.
SOAP note presents case study findings in a logical, meaningful, and understandable sequence following provided format.
Paper does not contain all components and/or may be missing data.
OR
SOAP note is not written in SOAP note format as outlined in the NR 601 SOAP note format document.
Paper is missing three or more required sections or
Diagnoses or
plans are sometimes unclear to follow and may not always be relevant to topic.
Paper is not relevant to case study patient
OR
SOAP note is not relevant to case study.
Format Subtotal
_____of 20 points
Total Points
_____of 200 points
Mrs G, a 50 year old Hispanic female, presents to the office for sick visit. Lately she has been very fatigued and just does not seem to have any energy. She is also gaining weight since menopause last year. She joined a gym and forces herself to go twice a week, where she walks on the treadmill at least 30 minutes but she has lost very little weight. She states that exercise seems to make her even more hungry and thirsty, which is not helping her weight loss. She came to the clinic today to discuss why she is so tired and get some weight loss advice. She also states she thinks her bladder has fallen because she has to go to the bathroom more, recently she is waking up twice a night to urinate and seems to be urinating more frequently during the day. This is irritating to her, but she is able to fall immediately back to sleep.
Current medications: Tylenol daily for knee pain. Daily multivitamin
PMH: Has left knee arthritis. Had chick pox and mumps as a child. Vaccinations up to date.
GYN hx: G1 P1. 1 child, full term, wt 9lbs 2 oz. LMP 15months ago. No history of abnormal PAP
FH: parents alive, well, child alive, well. No siblings.
SH: works from home full time as a telemarketer. Married. No tobacco history, 1-2 glasses wine on weekends. No illicit drug use
Allergies: NKDA, allergic to cats and latex
Vital signs: BP 130/82; pulse 80, regular; respiration 20,regular
Height 5’2”, weight 190 pounds
General: obese female in no acute distress. Alert, oriented and cooperative.
HEENT: head normocephalic. Hair thick and distribution throughout scalp. Eyes without exudate, sclera white. Wears contacts. Tympanic membranes gray and intact with light reflex noted. Pinna and tragus nontender. Nares patent without exudate. Oropharynx moist without erythema. Teeth in good repair, no cavities noted. Neck supple. Anterior cervical lymph nontender to palpation. No lymphadenopathy. Thyroid midline, small and firm without palpable masses.
CV: S1 and S2 RRR without murmurs or rubs
Lungs: Clear to auscultation bilaterally, respirations unlabored.
Abdomen- soft, round, nontender with positive bowel sounds present; no organomegaly; no abdominal bruits. No CVAT.
Labwork:
CBC: WBC 6,000/mm3 Hgb 12.9 gm/dl Hct 40% RBC 4.6 million MCV 92 fl MCHC 34 g/dl RDW 13.8%
UA: pH 5, SpGr 1.015, Leukocyte esterase negative, nitrites negative, 1+ glucose; 1+ protein; negative for ketones
CMP:
Sodium 138
Potassium 4.2
Chloride 101
CO2 29
Glucose 90
BUN 12
Creatinine 0.7
GFR est non-AA 90 mL/min/1.73
GFR est AA 101 mL/min/1.73
Calcium 9.4
Total protein 7.6
Bilirubin, total 0.7
Alkaline phosphatase 72
AST 25
ALT 29
Anion gap 8.11
Bun/Creat 17.7
Hemoglobin A1C: 7.7 %
TSH: 2.30, Free T 4 0.7
Cholesterol: TC 228 mg/dl, LDL 143 mg/dl; VLDL 36 mg/dl; HDL 37mg/dl, Triglycerides 232
EKG: normal sinus rhythm
NUR601 week 5 case study assignment paper