Assignment 7

You will create a realistic case study and include appropriate and pertinent clinical information that will be covering the following:

Subjective data: Demographics; Chief Complaint; History of the Present Illness (HPI) that includes the presenting problem and the 8 dimensions of the problem; Medications; Allergies; Past medical history; Family history; Past surgical history; Social history; Review of Systems (ROS)
Objective data: Vital signs; Physical exam, Labs (reviewed from the patient’s medical records, if no lab/diagnostic tests were done recently to review, you must indicate that to receive credit).
Assessment: Differential diagnosis; Primary Diagnosis
Plan: Laboratory and diagnostic tests; Pharmacologic treatment plan; Non-pharmacologic treatment plan; Anticipatory guidance (primary prevention strategies); Follow up plan.
Other: Incorporation of current clinical guidelines; Integration of research articles; Role of the Nurse practitioner

Chief Complaint (Reason for seeking health care) – S
Includes a direct quote from patient about presenting problem
Demographics – S
Begins with patient initials, age, race, ethnicity and gender (5 demographics)
History of the Present Illness (HPI) – S
Includes the presenting problem and the 8 dimensions of the problem (OLD CARTS – Onset, Location, Duration, Character, Aggravating factors, Relieving factors, Timing and Severity)
Allergies – S
Includes NKA (including = Drug, Environmental, Food, Herbal, and/or Latex or if allergies are present (reports for each severity of allergy AND description of allergy)
Review of Systems (ROS) – S
Includes a minimum of 3 assessments for each body system and assesses at least 9 body systems directed to chief complaint AND uses the words “admits” and “denies”

Vital Signs – O
Includes all 8 vital signs, (BP (with patient position), HR, RR, temperature (with Fahrenheit or Celsius and route of temperature collection), weight, height, BMI (or percentiles for pediatric population) and pain.)
Labs – O
Includes a list of the labs reviewed at the visit, values of lab results and highlights abnormal values OR acknowledges no labs/diagnostic tests were reviewed.
Medications – O
Includes a list of all of the patient reported medications and the medical diagnosis for the medication (including name, dose, route, frequency)
Screenings – O
Includes an assessment of at least 5 screening tests
Past Medical History – O
Includes, for each medical diagnosis, year of diagnosis and whether the diagnosis is active or current AND there is a medical diagnosis for each medication listed under medications
Past Surgical History – O
Includes, for each surgical procedure, the year of procedure and the indication for the procedure
Family History – O
Includes an assessment of at least 4 family members regarding, at a minimum, genetic disorders, diabetes, heart disease and cancer.
Social History – O
Includes all 11 of the following: tobacco use, drug use, alcohol use, marital status, employment status, current and previous occupation, sexual orientation, sexually active, contraceptive use, and living situation.
Physical Examination – O
Includes a minimum of 4 assessments for each body system and assesses at least 5 body systems directed to chief complaint

Diagnosis – A
Includes a clear outline of the accurate principal diagnosis AND lists the remaining diagnoses addressed at the visit (in descending priority)
Differential Diagnosis – A
Includes at least 3 differential diagnoses for the principal diagnosis

Pharmacologic treatment plan – P
Includes a detailed pharmacologic treatment plan for each of the diagnoses listed under “assessment”. The plan includes ALL of the following: drug name, dose, route, frequency, duration and cost as well as education related to pharmacologic agent. If the diagnosis is a chronic problem, student includes instructions on currently prescribed medications as above.
Diagnostic/Lab Testing – P
Includes appropriate diagnostic/lab testing 100% of the time OR acknowledges “no diagnostic testing clinically required at this time”
Education – P
Includes at least 3 strategies to promote and develop skills for managing their illness and at least 3 self-management methods on how to incorporate healthy behaviors into their lives.
Anticipatory Guidance – P
Includes at least 3 primary prevention strategies (related to age/condition (i.e. immunizations, pediatric and pre-natal milestone anticipatory guidance)) and at least 2 secondary prevention strategies (related to age/condition (i.e. screening))
Follow up plan – P
Includes recommendation for follow up, including time frame (i.e. x # of days/weeks/months)
References
High level of APA precision
Grammar
Free of grammar and spelling errors
Incorporation of Current Practice Guidelines
Includes recommendations from at least 1 professional set of practice guidelines (although not the current version)
Role of the Nurse Practitioner
Includes a discussion of the role of NP pertaining to the assessment, work up, collaboration and management of the case presented AND gives at least 1 example pertaining to each of the 4 areas (assessment, work up, collaboration and management).