Week 5: Case Study Assignment

Week 5: Case Study Assignment

Week 5: Case Study Assignment

Review the provided patient visit information. You are provided with the subjective and objective exam findings. As the provider, you are to diagnose the case study patient and develop the management plan for this case study patient.  Keep in mind this is a complex patient who has more than one diagnosis, which is common in primary care.

Use the provided case study template for your paper. Review the APA Manual to adhere to APA formatting.

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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:

1. ICD 10 code.
2. A brief pathophysiology statement which is no longer that two sentences, paraphrased and includes common signs and symptoms of the diagnosis and proper citation.
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. An evidence-based rationale statement, which summarizes why the diagnosis was chosen.
5. 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)

1. 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.
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 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.
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 with in text citation. Review the ADA guidelines for specific follow up recommendations.
5. 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.  Week 5: Case Study Assignment.

Case Study:

Mr Jones, a 60 year old African American male, presents to the office for a planned 6 month follow up visit for hyperlipidemia and weight loss. At the previous visit, Mr Jones was educated on lifestyle recommendations. He reports he has been following dietary recommendations “as good as he could remember” and exercising as recommended. He reports some new concerns today. He reports that he has been experiencing increased fatigue for about the last 10 weeks. He has a health club membership and attends 3-4 times a week. He walks on the treadmill at least 30 minutes as you directed and lifts weights but he has not lost any weight, in fact he has gained 7 pounds.

He doesn’t understand what he is doing wrong and is requesting more education and suggestions for weight loss. He reports that exercise makes him even more hungry and thirsty. He requests further evaluation for his fatigue. He reports he has to go to the bathroom more often- he is waking up during the night to urinate and seems to be urinating more frequently during the day. This has been occurring for about 2 months. No other GU symptoms such as painful urination, dribbling or changes in sexual functionhave been noted.

Current medications: Simvastatin, 10 mg daily, Tylenol 500 mg 2 tabs in AM for knee pain. Daily multivitamin and turmeric. PMH: Hyperlipidemia. Right knee OA (for 2 years) Had chicken pox as a child. Vaccinations up to date. Colonoscopy WNL 7 years- to repeat at 10 years FH: parents deceased, child alive, well. No siblings. SH: Divorced. Business executive, job requires frequent travel. Drinks 1-2 beers daily. Former smoker, quit 5 years ago. No reports illicit drug use. No CBD use.

Allergies: allergic to Bactrim, strawberries, cats and pollen. No latex allergy Vital signs: BP 119/77; pulse 80, regular; respiration 16, regular Height 5’9.5”, weight 210 pounds General: AA male in no acute distress. Alert, oriented and cooperative.

Skin: warm dry and intact. No lesions noted. HEENT: head normocephalic. Hair thinning distribution across crown. 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 and posterior 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