Subjective Data (S)

Patient has swollen lower extremities, redness and ulcers.

Identifying Data:

Initials: N/A

Age: 90 years

Race: Caucasian

Gender: Female

CC/Chief Complaint: 90 year old female presents with bilateral swelling, redness and ulcers to lower extremities (ulcers are new).

HPI: Patient is a 90-year-old woman with a past medical history of hypertension, chronic obstructive pulmonary disease, morbid obesity, type 2 diabetes mellitus and gastroesophageal reflux disease. She also has chronic arthritis with multi-joint discomfort and difficulty walking. She is on chronic opioid therapy. She felt not to be a candidate for joint replacement due to multiple medical issues and advanced age. She was brought to the emergency department today for evaluation of increasing pain, redness, swelling and bruising of the lower extremities. She has chronic venous stasis dermatitis but now appears to have bilateral lower leg cellulitis. She is planning short-term rehabilitation. She will be admitted for IV antibiotic therapy and pain management.

Location: Joints and lower extremities.

Duration: 1 week

Character: N/A.

Aggravating factors: Moving. 

Relieving factors: N/A

Timing: Ongoing, past few weeks.

Severity: Pain is at a medium to high level (7 to 8 in FACES pain scale), pt reports inability to participate in usual activities.

Review of Systems:

Constitutional: No fever or weight loss.

Skin: Bilateral lower leg redness pain swelling and small blisters which have ruptured and oozing.

Eyes: No recent vision problems or eye pain.

ENT: No congestion, ear pain or sore throat.

Endocrine: No thyroid problems. Type II diabetes mellitus.

Cardiovascular: No chest pain. No palpitations.

Respiratory: No cough, congestion or wheezing.

Gastrointestinal: she complains of reflux and a hiatal hernia and periumbilical pain which is intermittent.

Genitourinary: No dysuria. No urinary frequency.

Musculoskeletal: Generalized chronic joint pain.

Neurologic: No headache. No focal weakness.

 

Past Medical History

Past Surgical History:

• Hospital observation service, per hour (05/19/2018)
• Introduction of Anesthetic agent into joints, percutaneous approach (04/16/2018)
• Introduction of Anti-inflammatory into joints, percutaneous approach (04/16/2018)
• Appendectomy
• Hernia repair
• Hysterectomy
• Knee replacement
• Shoulder surgery

Social history:

• Alcohol (Use alcohol screen below for admitted Pats) – No risk, 05/19/2018
• Blood management: Accepts blood
• Employment/School – No risk, 05/19/2018
• Home/Environment – No risk, 05/19/2018
• Substance abuse – No risk, 05/19/2018
• Tobacco – No risk, 05/19/2018; unknown if ever smoked, household tobacco concerns: No

Allergies: None

Past Medical History

Ongoing

• Arthritis
• Benign essential hypertension
• COPD (Chronic obstructive pulmonary disease)
• Degenerative joint disease
• Diabetes mellitus
• Diabetic neuropathy
• Emphysema
• Encounter for preventive health examination
• Esophagitis
• GERD (Gastroesophageal reflux disease)
• Hypertension
• Hypothyroidism
• Mixed hyperlipidemia
• Osteoarthritis of hip
• Type 1 diabetes mellitus

Family History: Cardiovascular disease and diabetes mellitus

Immunizations: Up to date

Lab results:

CBC	WBC	HGB	HCT	PLT
SEP 27 12:18	7.5	11.1	36.4	196
BMP	Na	K	Cl	CO2	BUN	CR	Gluc	Ca
SEP 27	139	4.3	97	32	25.1	1.02	178	8.6
ABG	pH	PaCO2	PaO2	HCO3
---- No Results ----
COAG	INR	PT
---- No Results ----
Troponin
---- No Results ----
BNP
---- No Results ----
LFT	Alb	ALK	ALT	AST	DBili	TBili	Prot
SEP 27 12:18		3.7	71	14	21	0.5	6.5

 

Objective data: (O)

Physical Examination:

Vital Signs: T:98.0°F,  P:88, R:20, BP: 91/74, SpO2:98%, WT:103.64kg, BMI:44.86

General:  Pt is in no acute distress, morbidly obese, awake and alert. Vitals reviewed.

Eyes: Pupillary response normal. Sclerae normal

Ears: Normal findings

Nose: Sinuses don’t elicit pain to palpation

Throat: White tonsillar exudate and erythema, palatal petechiae

Neck: Non-tender to palpation

Lymph nodes: No cervical or supraclavicular adenopathy.

Cardiovascular: Normal heart tones, normal pressure, slightly elevated heart rate

Lungs: Normal to auscultation

Abdomen: Soft, obese and protuberant. Active bowel sounds all quadrants, palpation to abdomen without tenderness, including liver, percussion to abdomen normal, palpation of spleen without tenderness. There is a ventral surgical scar with a periumbilical hernia without tenderness, no HSM.

Neuro: CN II-XII intact grossly, she moves all 4 extremities with discomfort, some loss of sensation in the feet bilaterally. Pt is alert and oriented to surroundings,

Psychiatric: Oriented x3, normal mood and affect.

Extremities: No petechia or edema

Skin: Bilateral lower extremity erythema and swelling with a few small ruptured blisters.

Assessment

Diagnosis:

1. Cellulitis of multiple of lower extremity (L0.3119)
2. Diabetes Mellitus type 2, goal A1C to be determined (E11.9)
3. Edema of lower legs due to peripheral venous insufficiency (I87.2)
4. Morbid obesity due to excess calories (E66.01) 

Plan

The patient is a 90-year-old woman with a past medical history of hypertension, chronic obstructive pulmonary disease, morbid obesity, type 2 diabetes mellitus and gastroesophageal reflux disease. She also has chronic arthritis with multi-joint discomfort, and difficulty walking. She is on chronic opioid therapy.

She was brought to the emergency department today for evaluation of increasing pain redness swelling and bruising of both lower extremities. She has chronic venous stasis dermatitis but now appears to have bilateral lower leg cellulitis. She is planning short term rehabilitation. She will be admitted for IV antibiotic therapy and pain management.

I will order vancomycin and ceftriaxone. She will be continued on all of her usual Medications hydromorphone 4 mg every 4 hours as needed for pain. She also takes Lyrica and Celebrex. I will order a fentanyl patch as I believe the patient's pain may be better controlled with a long-acting medication. Hopefully on the patch she will require fewer doses each day of hydromorphone.

I will continue her Lantus insulin at 80% of her usual dose and monitor her with Accu-Checks and coverage. She will be placed on a low-sodium diabetic diet. I will order Lovenox for DVT prophylaxis. She will be evaluated by physical therapy and occupational therapy. She will most likely require short-term rehabilitation placement. Additional plan will depend upon her course over the next 24 to 48 hours.

 

 

Medications

Colace, 100 mg Oral, Daily

Dextrose 50% in Water, IV Push, Once, PRN

Dextrose 50% in Water, IV Push, Once, PRN

Dextrose 50% in Water, IV Push, Once, PRN

Duloxetine, 60 mg Oral, Daily

DuoNeb, NEB, RTq6hr (respiratory ther)

Fentanyl Patch, 25 mcg TD, 972hr

Fentanyl Patch Removal, TD, 972hr

Furosemide Tab, 40 mg Oral, Daily

Glucagon, 1 mg IM, Once, PRN

Glucagon, 1 mg IM, Once, PRN

Glucose 40% gel, Oral, Once, PRN

Glucose 40% gel, Oral, Once, PRN

HYDROmorphone, 4 mg Oral, q4hr (specified start), PRN

Incruse Ellipta, 62.5 mcg INH, Daily

Insulin lispro medium dose coverage, Subcutaneous, Before meals and bedtime

Lantus, 40 unit Subcutaneous, BID

Lisinopril, 5 mg Oral, Daily

Lovenox, 40 mg Subcutaneous, Daily

Lyrica, 100 mg Oral, BID

Magnesium oxide, 500 mg Oral, QHS

MiraLax, 17 gm Oral, QHS, PRN

Multivitamin, Oral, Daily

Nystatin 100,000 units/g topical powder, TOP, TID

Omeprazole 40 mg oral delayed release capsule, 40 mg Oral, Daily

Saline Flush 0.9%, IV, q12hr, PRN

Saline Flush 0.9%, IV, Daily

Simvastatin, 10 mg Oral, Daily

Synthroid, 125 mcg Oral, QAM

Tamsulosin, 0.4 mg Oral, QPM

Vancomycin IVPB, 1 gm IV Piggyback, q12hr

Home Medications Active

Aspirin Enteric Coated 81 mg oral delayed release tablet 81 mg = 1 tab, Oral, Daily

Celebrex 100 mg, Oral, q12hr

Colace 100 mg oral capsule 100 mg = 1 cap, Oral, Daily

Combivent 1 inh, PRN, INH, q6hr

Duloxetine 60 mg oral delayed release capsule 60 mg = 1 cap, Oral, Daily

Furosemide 40 mg oral tablet 40 mg = 1 tab, Oral, Daily

HYDROmorphone 4 mg oral tablet 4 mg = 1 tab, PRN, Oral, q4hr (specified start)

Lantus 50 UNITS, Subcutaneous, BID

Lisinopril 5 mg, Oral, Daily

Lyrica 100 mg, Oral, BID

Magnesium oxide 500 mg oral tablet 500 mg = 1 tab, Oral, QHS

Miralax 17 gm, PRN, Oral, QHS

Multivitamin 1 tab, Oral, Daily

Nystatin 100,000 units/g topical powder 1 app, TOP, TID

Omeprazole 40 mg oral delayed release capsule 40 mg = 1 cap, Oral, Daily

Simvastatin 10 mg, Oral, Daily Spiriva 18 mcg inhalation capsule 1 puff(s), INH, RTDaily Symbicort , INH, BID

Symbicort 160 mcg-4.5 mcg/inh inhalation aerosol 2 puff(s), INH, Daily

Synthroid 125 mcg, Oral, QAM

Tamsulosin 0.4 mg oral capsule 0.4 mg = 1 cap, Oral, QPM

Voltaren Topical 1% topical gel 1 app, TOP, QID

 

Diagnostic Tests:

• Monospot test: for of heterophile antibody test, a rapid test for mononucleosis to detect for the presence of the Epstein Barr Virus (EBV), 70-90% sensitive, if negative could proceed with EBV serological testing. If this spot test is positive, most likely patient has infectious mono.
• CBC with differential: if this is mono, the total number of lymphocytes is elevated with atypical lymphocytes greater than 10%. A peripheral smear should be obtained if other blood disorder are suspected.
• Rapid Strep-85% sensitive for streptococcal pharyngitis, can be done easily in office, if positive, antibiotic therapy can be initiated and throat culture would not be required. If this is negative, consider the throat culture if indicated by the Centor criteria and risks such as exposure or contact with others was noted.
• Diagnostic test 4: throat culture: indicated according to modified Centor criteria, confirms presence or absence of pharyngeal streptococcus
• Diagnostic Test 5: Lateral neck films or CT scan: consider these tests to rule out or confirm retropharyngeal abscess or epiglottitis 

Summary

The patient is a 90-year-old woman with a past medical history of hypertension, chronic obstructive pulmonary disease, morbid obesity, type 2 diabetes mellitus and gastroesophageal reflux disease. She also has chronic arthritis with multi-joint discomfort, and difficulty walking. She is on chronic opioid therapy.

She was brought to the emergency department today for evaluation of increasing pain redness swelling and bruising of both lower extremities. She has chronic venous stasis dermatitis but now appears to have bilateral lower leg cellulitis.

On physical exam she has temperature of 98.0°F, her abdomen is soft, obese and protuberant. Active bowel sounds all quadrants, palpation to abdomen without tenderness, including liver, percussion to abdomen normal, palpation of spleen without tenderness. There is a ventral surgical scar with a periumbilical hernia without tenderness, no HSM. Pt moves all 4 extremities with discomfort, some loss of sensation in the feet bilaterally. Her skin presents bilateral lower extremity erythema and swelling with a few small ruptured blisters.

 

Patient Education: Patient was educated about the nature of her condition and the management of her pain with opioids.

 

Bibliografía

Papadakis, M. A., McPhee, S. J., & Rabow, M. W. (2018). CURRENT Medical Diagnosis and Treatment 2019 (Fifty-eighth edition ed.). (S. Allen, Ed.) New York, New York, United States of America: McGraw Hill Professional.

Woo, T. M., & Robinson, M. V. (2015). Pharmacotherapeutics for Advanced Practice Nurse Prescribers (Fourth edition ed., Vol. I). (R. H. Craven Jr., Ed.) Philadelphia, Pennsylvania, United States of America: F.A. Davis Company.

 

References

1. Papadakis, M. A., McPhee, S. J., and Rabow, M. W. (2018). CURRENT Medical Diagnosis and Treatment 2019 (Fifty-eighth edition ed.). (S. Allen, Ed.) New York, New York, United States of America: McGraw Hill Professional.
2. Woo, T. M., and Robinson, M. V. (2015). Pharmacotherapeutics for Advanced Practice Nurse Prescribers (Fourth edition ed., Vol. I). (R. H. Craven Jr., Ed.) Philadelphia, Pennsylvania, United States of America: F.A. Davis Company.

 

Week 6 SOAP

Name

University

 

Name: XY	Date:
Age: 34 years	Sex: Female
Subjective
CC: “I am experiencing a foul smelling white discharge from my vagina, itchiness and urgency to visit the washrooms.”
A 34-year-old female who presents in the clinic with complains of foul smelling white discharge from her vagina for three weeks which she experiences together with itchiness around her vitals. She also complains about the urgency to visit the washroom like 3x in an hour which has a burning sensation. No distress noted in the patient. The patient denies having a fever, abdominal cramps, nausea, vomiting, vaginal bleeding, and diarrhoea, changes in stool consistency or hematuria. She has never experienced this symptom before and has no history of STDs.
Social history: Pt is married with two children, a stay at home mother with no history of smoking nor drinking. She reports having just one sex partner and three lifetime partners although reports that her husband has several sex partners. She does not use a condom as she claims to be allergic to latex. The patient states to be a form four leaver with no further education. She claims to be physically active as she has enrolled in a gym and does all house chores. Consumes regular healthy diets with occasional caffeine consumption.
Medications None
Family history + For arthritis in mother aged 61. + For DM and HTN in father aged 66.
PMH Allergies; no drug allergy, allergic to animal protein when taken continuously, allergic to latex, no environmental allergies. Blood transfusion / operations: None. Chronic illness: None Hospitalisation: None Habits: does not smoke or drink.
Obstetrical hx: Two pregnancies, both pregnancies delivered alive via vaginal delivery mode with babies at term with no complications. No hx of abortions nor miscarriages. LMP three weeks ago, heavy but normal, a flow of 3/7, no complains of bleeding nor spotting since then, no previous PAP smear nor mammogram. Currently on IUD method of family planning for the past one year four months.
ROS General: pt. denies any fevers, chills, fatigue and weakness. HEENT: denies any hearing and vision problems, oral sores, nasal congestions and headaches. Cardiac: denies of any palpitations or DOB. GI: denies of diarrhea, constipation, nausea, vomiting, heartburn, difficulty in swallowing. Neuro: denies of any numbness, weakness, seizures and paresthesia. Gynecological: as presented above. Denies of vesicular lesions on the labials, change in urine color and any complaints with the previous LMP. Denies any breast lumps, tenderness or breast discharge. Musculoskeletal: denies of any joint swellings, backaches, stiffness and hx of fracture.
PE.
Weight: 147 lbs. Height: 5ft 5 inches BMI: 24.4	Temp: not taken. BP: 132/84 mmHg Pulse: 84 beats per min
General appearance: XY is a young female with no distress, alert and well-nourished.
Skin: Skin is pink, warm and dry. (PWD)
HEENT: Head normocephalic, eyes and ears not checked due to time limits, non-enlarged thyroids, no nasal congestions, mucous membranes moist, no thyromegaly nor nodules on the neck. Neck soft and not stiff.
Cardiac and respiratory. Lungs CTA, lymph nodes non-palpable, chest posteriorly bilateral, no murmurs or clicks heard.
Abdomen: Non-distended, no hepatomegaly, non-tender and presence of BS.
Extremities: No edema, warm, cap refill <2min and no skin breaks noted.
Breasts: Symmetrical, tender, no discharge or swellings.
Genitourinary: Shaven pubic hair scant, white foul smelling discharge noted, pink vaginal walls, smooth uterus within normal limits, non-palpable ovaries, no hemorrhoids or masses.
Psychiatric: Alert, clear speech and answers quizzes appropriately.
Lab tests: Chlamydia culture, swab test, urine culture, HbA1C- awaiting results.
Diagnosis: Differential diagnoses Candidiasis This is an infection which is commonly known as yeast infection where the healthy yeasts in the vagina out grow beyond control. This thus leads to irritation and itchiness around the vagina. This condition can be promoted by some factors including hormonal changes especially during menstruation, pregnancy, compromised immune system, diabetes and side effects to some drugs (Glaser, et.al). This infection is also seen in men but not as common. Sample used is mostly urine.   Herpes simplex This is a condition caused by a virus that attacks the vaginal cavity. It has two types, type 1 is transmittable through oral secretions and thus can be spread through kissing, sharing toothbrushes, utensils, or coming into contact with a person with skin sores. Type 2 is transmitted through sexual intercourse with an infected person. The common reported symptom is mostly pain and itching when passing urine (Koelle DM, Corey L). Chlamydia This is a rampant sexually transmitted disease whose incubation period for symptoms is long such that one would rarely know if they are having it. Some of its symptoms are pain around the pelvic area especially during sex, abnormal discharge from the vagina and sometimes it could cause bleeding in the vagina. If this condition is not treated, it could lead to complications such as bareness, ectopic pregnancy and other pregnancy complications (Bayramova, et.al).
Plan Medication: fluconazole cream OD for 7 days, flagyl 500mg BD for 5 days. Non-medical treatment: drinking of plenty of water, 6-8 glasses per day, regular changing of tampons and wiping front to back after using the washroom. Follow-up: in 1 week if symptoms persist.

 

 

 

 

 

 

References

1. Glaser, AP; Schaeffer, AJ (November 2015). "Urinary Tract Infection and Bacteriuria in Pregnancy".
2. Koelle DM, Corey L (2008). "Herpes simplex: insights on pathogenesis and possible vaccines"
3. Bayramova, Firuza and Jacquier, Nicolas and Greub, Gilbert (2018). "Insight in the biology of Chlamydia-related bacteria". Microbes and infection.

 

 

Complete a focused SOAP note for the case study as noted below and address the additional discussion questions. For the SOAP note section, you do not need to use complete sentences and must use approved nursing/medical abbreviations. For the discussion sections you must use Harvard format, using correct sentence structure and spelling. Include a properly written cover sheet. Be succinct on both sections of the paper. The rubric is attached at the end of this document, be sure to review the rubric as you are writing so that you will have a well written paper.

Case Scenario 

CC: “I am here for my diabetic check-up”

65-year-old Saudi woman presents for her yearly diabetic checkup. She was diagnosed with Type 2 diabetes mellitus 15 years ago. Currently she is prescribed Metformin 1000 mg by mouth twice daily with meals and empagliflozin 10 mg by mouth every morning. Medical history includes hypertension, diagnosed 20 years ago, for which she takes losartan 100 mg and hydrochlorothiazide 25 mg by mouth each morning, dyslipidemia for which she takes Atorvastatin 40 mg by mouth at bedtime, and frequent tension headaches for which she takes paracetamol 500 mg once for each headache episode for good relief. She reports that she takes all medication as ordered and experiences no side effects. She eats a standard Saudi diet except that she and her husband go out to eat at least 4-3 times each week for dinner and travel to Dubai at least 2 times each year where they eat 3 meals per day in restaurants. When she eats in restaurants, she doesn’t follow a diabetic diet. She walks 2-3 miles 4 times each week at the mall. She is married with 3 healthy grown children. She lives in her owned home with her husband and youngest daughter. She is comfortable in her home and has a happy relationship with her husband, children, and 4 grandchildren. She denies any symptoms of depression. Both her mother and father had T2DM. Her mother died at age 75 from an MI and her father died at age 55 from an MI and renal failure. She has 3 siblings, all of whom have T2DM. Her youngest brother had an MI at age 58 but is doing well post stent placement 2 years ago. Headaches occur about once monthly and are not related to anything that she can tell. Denies other pain except for some numbness and tingling in her toes, with pain at 4/10.  Denies any recent foot ulcers. Denies nausea/vomiting/diarrhea/constipation/black/bloody stools. Denies reflux/heartburn. Denies shortness of breath, cough or wheezing, dizziness, difficulties with balance, or falls. Denies chest pain or palpitations. Denies joint pain, stiffness, or swelling. Denies rashes but does note she has very dry skin that improves with twice daily application of moisturizers. Had a UTI 6 weeks ago for which she was given TMP-SMX 960 mg twice daily for 2 days which resolved the UTI. She has not been sexually active with her husband for the past 2 years as neither have any desire for conjugal intimacy. She c/o burning with voiding and urgency for the past 3 days but denies chills, incontinence, or CVP pain. She sees the ophthalmologist for yearly eye exam, last exam was 6 months ago and was normal, per patient report. She has declined PAP, pelvic exam, mammography, colonoscopy but did have a bone density last month.

Appears well groomed and is oriented to person, place, and time. Skin is warm and notably dry with minor flaking, no open lesions. Scattered actinic keratoses on neck and trunk. Conjunctivae white, moist, without drainage.  Red reflex present. Optic disc round, well defined bilaterally. Macula is without visible lesions. No A-V nicking noted. Oropharynx is pink, moist without lesions, dentition is in good repair. Trachea is midline, thyroid is palpable and within expected limits, no nodules palpated. Lungs clear to auscultation bilaterally, anterior and posterior, without adventitious sounds. Heart with regular rate and rhythm, no murmurs, gallops, or rubs. Abdomen soft, bowel sounds active x 4. Suprapubic tenderness 5/10 with palpation. No CVP pain on percussion bilaterally. MSK not examined. LOPS (loss of protective sensation) 6/10 bilaterally including plantar surface distal 1/3 of foot and 10 toes, PS (protective sensation) 4/10 for remainder of foot by microfilament examination. Previous HgA1c 7.9% 3 months ago and 7.7% 6 months ago.

Vital signs: Weight 90.7 kg, Ht. 1.7m, BMI 31.3, B/P 128/82, HR 89, RR 18, Temp 36.7 C, PO2 97% on room air.

Bone density results: T score: -1.5 (Reference range: Normal T-score > -1, Osteopenia between -1 and -2.5; Osteoporosis below -2.5)

Laboratory Results

These results were obtained fasting 2 days prior to this appointment:

Test	Result	Adult Reference Range
Glucose	205	Fasting: 70 - 110 mg/dL
Calcium	9.1	8.2 - 10.6 mg/dL
Albumin	4.5	3.5 - 5.0 gm/dL
Total Protein	7.1	6.0 - 8.4 gm/dL
Sodium	139	133 - 146 mEq/L
Potassium	4.8	3.5 - 5.4 mEq/L
CO2	34	23 to 29 mEq/L
Chloride	102	98 - 106 mEq/L
BUN	16	7 - 18 mg/dL
Creatinine	1.3	0.6 - 1.2 mg/dL
GFR	47	> 60 mL/min/1.73m2
ALP	87	44 to 147 IU/L
ALT	18	1 - 21 units/L
AST	22	7 - 27 units/L
Total Bilirubin	0.6	Up to 1.0 mg/dL
HgA1c	8.6	5.7 %

 

Thyroid Panel
Test	Patient results	Adult Reference Ranges
TSH	0.30	0.27 – 4.20 μIU/mL
T4	10.2	4.5-11.7 μg/dL
T3	180	80-200 ng/dL
Antithyroglobulin Antibody	50	<115
Antithyroid Peroxidase Antibody (Anti-TPO)	22	<34

 

 

Test	Result	Adult reference Range
Red blood cell count	5.1	4.2 - 6.9 million/µL/cu mm
Hematocrit	40%	Female: 37 - 48%
Platelet count	280,000	150,000 - 350,000/mL
Hemoglobin	13	Male: 13 - 18 gm/dL Female: 12 - 16 gm/dL
WBC	8	4.3-10.8 × 103/mm3

 

Cholesterol panel: all within normal limits for age and gender.

This was checked today in the office lab:

Test	Results	Reference Standards
Color	Dark yellow	Yellow
Appearance	hazy	Clear
Specific Gravity	1.020	1.005 -1.030
pH	5.7	5.5 - 7.5
Protein	negative	Negative
Glucose	negative	Negative
Ketones	negative	Negative
WBC/HPF	20	0 – 5/HPF
RBC/HPF	3	0 – 5/HPF
Epithelial cells	few	None-few/LPF
Casts/LPF	2	Hyaline 0-3
Bacteria	many	None-few/HPF
Leukocyte esterase	positive	Negative
Nitrite	positive	Negative
HPF = high power field, LPF = low power field                 ML McGary 2019

Discussion: These will be graded as part of the plan section. Answer the following questions:

1. Based on your plan, what is your rationale for changing or not changing the diabetic medications? Include a discussion of either a or b, based on your plan.
1. If you changed the medications and /or dosages, what is your rational for choosing the drug(s) and doses you chose?
2. If you chose not to change the medications and/or dosages, what is your rationale for continuing the same medication regimen?
2.  What should this patient’s blood pressure, weight, and HgA1c goals be? Give the rational for each goal, specific to this patient.

 

 

Category	Exceptional                       3	Satisfactory                  2	Needs Improvement      1	Possibly Harmful                          0	Score
Subjective	Information is accurate and complete and is organized and concise. The documentation is comprehensive to include all CC, HPI, PMH, SH, FH, Allergies, Meds, ROS etc.	Accurate information provided (as in exceptional column), but could be more organized and succinct	Minor incorrect information and / or information placed in the incorrect location; omissions such as allergies, medications	Major incorrect information and / or major omissions that make it unlikely another provider would come to the same A and P; major omissions such as HPI, ROS, PMH etc.
Objective	Accurate information is organized and precise and does not include any major or minor omission.	Accurate information is provided, but could be more organized and succinct	Incorrect information, or contains minor, but important information, or incorrect placement of information is evident	Incorrect information (major) or omissions that make it unlikely another provider would come to the same A and P (such as lab results)
Assessment	Accurate information provided: complete and concise description to include the diagnosis, supported logically by subjective and objective data; cites guidelines as appropriate	Accurate information provided but could be more organized	Incorrect information (minor) provided such as drug therapy inconsistent with established guidelines; contains problem not discussed in S and O sections or information from P section	Incorrect information (major) included that could result in wrongly identified drug therapy which may result in patient harm
Plan	Complete and appropriate in every detail to include education, further investigation, follow up, referral (if indicated) etc.	Appropriate information (same as exceptional column), but with minor omissions	Missing or inconsistent information or using guidelines that are not appropriate; major omissions where another practitioner is unlikely to come up with the same plan	Contains errors that could result in patient harm; fails to address correct therapy; has missing or incorrect key educational points (e.g. drug side effects), follow up / referral)
Overall grammar / medical terminology / references	Appropriate word choice and terminology; no grammatical errors; appropriate up to date scientific references used, for instance textbooks, clinical practice guidelines	Few errors with word choice and terminology; fewer than 2 grammatical errors; up to date and appropriate sources used	Incorrect or inappropriate word choice or terminology (minor); greater than 3 grammatical errors; some sources are scientific / or up to date	Incorrect or inappropriate word choice or terminology (major); greater than 5 grammatical errors; few or no sources are up to date, inappropriate scientific references
Total (out of a possible 15)

 

Purpose

Course Outcomes

This assignment enables the student to meet the following course outcomes:

CO 1- Interpret subjective and objective data to develop appropriate diagnoses and evidence based management plans for patients and families with complex or multiple diagnoses across the lifespan.

CO 4 -Develop management plans based on current scientific evidence and national guidelines.

Requirements

For Week 1 of the course there is no case study given to you by the faculty. Instead you will be assigned to diseases to compare and contrast based on the first letter of your last name. This information will be posted in the course announcements under Week 1 Welcome as well as the “Assignment” portion of the Week 1 module.

A comparison and contrast assignment’s focus is to identify and explore similarities and differences between two similar topics. The goal of this exploration is to bring about a better understanding of both topics.

Week 1- Part 1: Due Wednesday by 11:59 p.m. MT

You will research the two areas of content assigned to you and compare and contrast them in discussion post in a discussion post. NOTE: A comparison and contrast assignment is not about listing the info regarding each disease separately but rather looking at each disease side by side and discussing the similarities and differences given the categories in the categories below. Evaluation of mastery is focused on the student’s ability to demonstrate specific understanding of how to diagnoses differ and relate to one another.

Address the following topics below:

• Presentation
• Pathophysiology
• Assessment
• Diagnosis
• Treatment

 

Throughout the Week: Participate in interactive dialogue with faculty and students responding to their Part 1 post moving the discussion forward. 

 

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
Total Points Possible = 100
Application of Course Knowledge	25 Points	22 Points	21 Points	10 Points	0 Points
	Post contributes unique perspectives/insights applicable to the identified diseases. Demonstrates course knowledge by thorough, thoughtful, evidence-based discussion of similarities and differences in reference to: ●        Presentation ●         Pathophysiology ●         Assessment ●         Diagnosis ●        Treatment	Post contributes unique perspectives or insights, but may lack some applicability/specificity to the assigned diseases.	Post has limited comparison/contrast perspective, insights and/or applicability to assigned disease.	Post perspectives are not consistent with current practice. Disease information is listed without comparison/contrast analysis.	Post offer no insight or application to the assigned diseases.
Support from Evidence-Based Practice (EBP)	25 Points	22 Points	21 Points	10 Points	0 Points
	Discussion post supported by evidence from appropriate sources published within the last five years. In-text citations and full references are provided.	Discussion post is partially supported by evidence from appropriate sources published within the last five years. In-text citations and full references are provided. Evidence-based reference(s) used but may not fully support first line treatment recommendations.	Sources may not be scholarly in nature or may be older than five years. In-text citations and/or full references may be incomplete or missing.	Citations to non-scholarly websites given as rationale to support differences in presentation, assessment, pathophysiology, diagnosis and treatment.	Discussion post contains no evidence-based practice reference or citation. *Students should note that factitious sources, sources that are clearly not read by the student and used, or sources that have incorrect dates will result in an automatic ZERO for this section for the week.
Organization	15 points	13 points	12 points	6 point	0 points
	Discussion post presented in a logical, meaningful, and understandable sequence.	Discussion post relevant to the topic but may be unclear or difficult to follow in places.	Discussion post not fully relevant to the topic. May be unclear or difficult to follow in places.	Discussion post sometimes unclear to follow and may not always be relevant to assigned diseases.	Discussion post is not relevant to assigned diseases.
Interactive Dialogue	25 Points	22 Points	21 Points	10 Points	0 Points
	Presents diseases together and responds substantively to at least one peer including evidence from appropriate sources, and all direct faculty questions posted.	Presents diseases together and responds substantively to at least peer.  Does include evidence from appropriate sources. Responds to some direct faculty questions.	Responds to a student peer and/or faculty questions but the post doesn’t include reflection on critical thinking behind the answers chosen. Does not include evidence from appropriate sources.	Responds to a student peer and/or faculty, but the nature of the response is not substantive.   Does not include evidence from any sources.	Does not respond to at least one peer and/or does not respond to faculty questions posted by Sunday.   *A zero may be assessed here for not responding to questions posed by faculty.
Grammar, Syntax, APA	10 points	9 points	8 points	4 point	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 or repeatedly makes the same errors after faculty feedback.
Participation Enters first post to part one by 11:59 p.m. MT on Wednesday.	0 points deducted			Points deducted for late or missing posts
	Enters first post to part one by 11:59 p.m. MT on Wednesday; enters peer/faculty response by Sunday 11:59 p.m. MT.			10% if submitted after Wednesday 11:59 p.m. MT and before the cut-off of Sunday 11:59 p.m. MT. Students will not receive credit for work in the threads submitted after Sunday 11:59 p.m. MT.