Realistic Clinical Case Study
For this assignment, you will develop a presentation on a realistic clinical case on a topic that is of interest to you.
Content Requirements You will create a PowerPoint presentation with a realistic case study and include appropriate and pertinent clinical information that will be covering the following:
1. Subjective data: Chief Complaint; History of the Present Illness (HPI)/ Demographics; History of the Present Illness (HPI) that includes the presenting problem and the 8 dimensions of the problem; Review of Systems (ROS)
2. Objective data: Medications; Allergies; Past medical history; Family history; Past surgical history; Social history; Labs; Vital signs; Physical exam.
3. Assessment: Primary Diagnosis; Differential diagnosis
4. Plan: Diagnostic testing; Pharmacologic treatment plan; Non-pharmacologic treatment plan; Anticipatory guidance (primary prevention strategies); Follow up plan.
5. Other: Incorporation of current clinical guidelines; Integration of research articles; Role of the Nurse practitioner
· The presentation is original work and logically organized, formatted, and cited in the current APA style, including citation of references.
· The presentation should consist of 10-15 slides
Incorporate a minimum of 4 current (published within the last five years) scholarly journal articles or primary legal sources (statutes, court opinions) within your work. Journal articles and books should be referenced according to APA style (the library has a copy of the APA Manual).
Case Study Rubric
Chief Complaint (Reason for seeking health care) – S: Includes a direct quote from patient about presenting problem
Demographics: 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, Environemental, 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.)
OutcomeLabs – 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).