Mrs. G, a 55 year old Hispanic female, presents to the office for her annual exam. She reports that lately she has been very fatigued and just does not seem to have any energy. This has been occurring for 3 months. 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 not lost any weight, in fact she has gained 3 pounds. She doesn’t understand what she is doing wrong. She states that exercise seems to make her even more hungry and thirsty, which is not helping her weight loss. She wants get a complete physical and 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 often, recently she is waking up twice a night to urinate and seems to be urinating more frequently during the day. This has been occurring for about 3 months too. This is irritating to her, but she is able to fall immediately back to sleep.
Current medications: Tylenol 500 mg 2 tabs 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: G2 P1. 1 SAB, 1 living child, full term, wt 9lbs 2 oz. LMP 15months ago. No history of abnormal Pap smear.
FH: parents alive, well, child alive, well. No siblings. Mother has HTN and father has high cholesterol.
SH: works from home part time as a planning coordinator. Married. No tobacco history, 1-2 glasses wine on weekends. No illicit drug use
Allergies: NKDA, allergic to cats and pollen. No latex allergy Vital signs: BP 129/80; pulse 76, regular; respiration 16, regular
Height 5’2.5”, weight 185 pounds
General: obese female in no acute distress. Alert, oriented and cooperative. Skin: warm dry and intact. No lesions noted
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 12.5 gm/dl Hct 41% RBC 4.6 million MCV 88 fl MCHC
34 g/dl RDW 13.8%
UA: pH 5, SpGr 1.013, Leukocyte esterase negative, nitrites negative, 1+ glucose; small protein; negative for ketones
CMP:
Sodium 139
Potassium 4.3
Chloride 100
CO2 29
Glucose 95
BUN 12
Creatinine 0.7
GFR est non-AA 92 mL/min/1.73 GFR est AA 101 mL/min/1.73 Calcium 9.5
Total protein 7.6 Bilirubin, total 0.6 Alkaline phosphatase 72
AST 25
ALT 29
Anion gap 8.10
Bun/Creat 17.7
Hemoglobin A1C: 6.9 %
TSH: 2.35, Free T 4 0.7
Cholesterol: TC 230 mg/dl, LDL 144 mg/dl; VLDL 36 mg/dl; HDL 38mg/dl, Triglycerides 232
EKG: normal sinus rhythm
instructions: Introduction: briefly discuss the purpose of this paper. (no more than 5 sentences)
Assessment: review the provided case study information.
Identify the primary and secondary diagnosis for the patient. Each diagnosis will include the following information:
- ICD 10 code.
- A brief pathophysiology statement which is no longer that two sentences, paraphrased and includes common signs and symptoms of the diagnosis and proper citation.
- 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).
- An evidence-based rationale statement, which summarizes why the diagnosis was chosen.
- Do not include quotes, paraphrase all scholarly information and provide an in-text 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)
- Diagnostics. List all labs and diagnostic test you would like to order. Each test includes a rationale statement following the listed lab, which includes the diagnosis requiring the test, the purpose of the test and how the test results will contribute to your management plan. Each rationale statement is cited. Include all future follow up labs for each listed diagnosis.
- 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.
- Education: section includes personalized detailed education on all five (5) subcategories: diagnosis, each medication purpose and side effects, diet, personalized appropriate 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 Clinical SOAP note guideline for more detailed information.
- 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 with in text citation. Review the ADA guidelines for specific follow up recommendations.
- Follow up: Follow up includes a specific time, not a time range, to return to PCP office for next scheduled appointment. Includes EBP rationale with in text citation.
Assessment of Comorbidities: in this section students will review the ADA Standards of Medical Care in Diabetes (the guidelines) Assessment of Comorbidities section on comorbidities subsection and choose one listed comorbidity. Students will discuss the significance of and the relationship between the patient’s primary diagnosis and the chosen comorbidity, explaining how one diagnosis affects the other diagnosis. Any recommended screening, diagnostic testing, and referrals are also included.
Medication costs: in this section students will research the costs of all prescribed and OTC monthly medications that you have prescribed and that the patient is currently taking that you would like to continue. Students may use Good Rx, Epocrates or another resource (students may 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 and provide the total costs of the month’s 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.
RUBRIC:
Assessment: Primary diagnosis
Presentation of the case study patient’s primary diagnosis includes the following required elements:
Diagnosis is consistent with the cited guideline recommendations or scholarly reference, ICD10 code is listed, rationale statement includes a one to two sentence paraphrased pathophysiology statement. The rationale statement includes pertinent positive and negative subjective and objective findings from the history and physical exam, which links this diagnosis to the case study patient. Pertinent lab results are included and interpreted within the rationale statement.
Assessment: Secondary diagnosis (es)
Presentation of the case study patient’s secondary diagnosis (es) include (s)the following required elements:
Diagnosis is consistent with the cited guideline recommendations or scholarly reference, ICD10 code is listed, rationale statement includes a one to two sentence paraphrased pathophysiology statement. The rationale statement includes pertinent positive and negative subjective and objective findings from the history and physical exam, which links this diagnosis to the case study patient. Pertinent lab results are included and interpreted within the rationale statement.
Evidence-Based Practice (EBP)
National guidelines are used to support all diagnoses and develop the management plan.
The American Diabetes Association Standards and Medical Care in Diabetes-2019 or later, (or article related to 2019 or later Guidelines) are used to support the primary diagnosis and develop the management plan.
Every diagnosis rationale must include an in-text citation to a scholarly reference as listed in the Reference Guidelines document. Each action step or order within all plan sections includes an in-text citation to an appropriate reference as listed in the Reference Guidelines document. Reference interpretation is accurate.
Plan: Diagnostics
All ordered diagnostics tests are linked to a diagnosis listed in the assessment section and include a paraphrased EBP rationale with citation and include date when test should be performed (ie: today, 1 week, 1 month). Further testing/diagnostics for the differential diagnosis is included. Plans are consistent with the cited guideline recommendations or scholarly reference.
Plan:Medications
The plan includes both prescribed and OTC medications written in prescription format. The plan includes a minimum of one OTC medication. Each prescribed and OTC medication is linked to a diagnosis listed in the assessment section
Diagnosis is clearly stated in the rationale statement. And includes a paraphrased rationale EBP rationale
Plan:Education
All education steps are linked to a diagnosis, paraphrased, and include an EBP rationale.
This section is written exactly how you would discuss the education to the patient. Use vocabulary which the patient can understand, not medical terminology.
Section includes personalized detailed education on diagnoses, medications, diet, exercise and any warning signs. Personalized diet and exercise recommendations are appropriate for the case study patient and include specific instructions for the case study patient such as a specific exercise- length of time to exercise and frequency/week. Any published diet recommendations, such as a Mediterranean diet, will include a rationale statement as to why this recommendation is beneficial for the case study patient.
Plans are consistent with the guideline recommendations or scholarly reference.
Plan:Referrals
All recommended referrals are appropriate for the patient diagnoses:
each referral is linked to a specific diagnosis each which was listed in the assessment section and includes a paraphrased EBP rationale. All referrals related to the primary diagnosis are obtained from the ADA guidelines.
Plans are consistent with the cited guideline recommendations or scholarly reference
Plan: Follow up
Follow up includes a specific time/date to return to PCP office. EBP rationale with in text citation is included. Only follow up information is listed in this section. Additional information, such as future testing, education or referrals are not listed in follow up but within the appropriate paper sections. Plans are EBP and consistent with the guideline recommendations.
Assessment of comorbidities
The ADA guidelines includes a Comprehensive Medical Evaluation and Assessment of Comorbidities section which includes comorbidities that providers should consider when managing disorders of glucose metabolism.
Choose one of the listed comorbidities from the ASSESSMENT OF COMORBIDITIES subsection*
Explain the significance of and the relationship between your primary diagnosis and your chosen comorbidity. Explain how one diagnosis affects the other diagnosis in no more than 3-5 sentences. Include any recommended screening, diagnostic testing, and referrals in no more than 2-3 sentences.
* the chosen comorbidity cannot be any secondary diagnosis already discussed in your paper’s assessment section.
Medication costs
All monthly medication costs are calculated, including the current medications the patient may be already taking.
A total cost for all the month’s medication is included.
All medications including OTCs are included.
Medication cost reference source is included. Summary/reflection statement regarding medication costs and any medications changes based on cost or polypharmacy concerns is included.
ASSIGNMENT FORMAT
Description
Grammar, Syntax, APA
APA format, grammar, spelling, and/or punctuation are accurate, or with zero to one error. All referenced information is cited, “according to” is not used. All cited information is paraphrased, no quotes are included in the paper.
Organization
Paper is developed in a logical, meaningful, and understandable sequence.
Provided assignment template is used to develop the paper. The rationale length does not exceed template directions. The paper length does not exceed 10 pages, excluding title page and references.
