NUR601 week 5 case study 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.

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

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