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NURS 640 Case Study One essay assignment

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NURS 640 Case Study One essay assignment

Case Study #1

T.P. is a new 32 y.o. female patient who has come to your clinic for the first time because she has been “more tired than normal”.  She does not have a PCP so she has been getting her health care on an occasional basis at an urgi-center in her neighborhood.  She works fulltime as a secretary, is married, and has 2 children who are in good health.  T.P. lives in a single-family home with her husband and 2 children and states her in-laws live ½ mile away.  Today she reports a several week history of feeling fatigued and is concerned she has cancer.  She called off work one day, something she never does, because she was “very tired” and did not think she would be able to work her 8-hour shift.  Her husband has become frustrated with her as she has been “too tired” to participate in the activities they share such as golfing and hiking.

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Chart information entered by the medical assistant:

CC: 32-year-old female presents to the office with a several week history of fatigue.

Last office visit:

VS:

BP-120/70, Resp-18, Pulse-72

Medications:

OCPs

Tylenol po prn for occasional tension headaches

PMH:

Denies

PSH:

S/P appendectomy

FMH:

Positive for heart disease and alzheimer’s disease

Social history:

Denies tobacco and illicit drug use.  Reports drinking 2 glasses of red wine each evening.

You review this information and enter the room.

HPI: (10 points)____________points earned

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NURS 400 – Nursing Care of Children
• NURS 400C – Required Clinical-NURS 400
• NURS 401 – Foundations of Public Health Nursing
• NURS 401C – Required Clinical-Nurs 401
• NURS 402 – Nursing Care of The Adult II
• NURS 402C – Required Clinical-Nurs 402
• NURS 404 – Leadership Contemporary Health Care
• NURS 405 – Senior Practicum
• NURS 405C – Required Clinical-Nurs 405
• NURS 406 – Leadership in Nursing
• NURS 407 – Transition to Professional Nursing
• NURS 407C – Required Clinical-NURS 407
• NURS 409 – Critical Care in Nursing
• NURS 412 – Nursing Care at End-Of-Life
• NURS 414 – Genetics in Nursing
• NURS 415 – Perioperative Nursing
• NURS 416 – Public Health Capstone
• NURS 496 – Independent Study
• NURS 600 – Theoretical Foundations of Nursing Practice
• NURS 601 – Evidence Based Practice In Nursing
• NURS 602 – Health Care Policy
• NURS 603 – Professional Role Development: Adv Practice Nurse
• NURS 605 – Professional Role Development: Nurse Educator
• NURS 610 – Health Promotion/Disease Prevention
• NURS 611 – Advanced Pathophysiology
• NURS 612 – Advanced Health Assessment
• NURS 615 – Advanced Pharmacotherapeutics
• NURS 619 – Leadership and Quality
• NURS 620 – Adult/Gerontology Health Care I
• NURS 621 – Adult/Gerontology Nurse Practitioner Practicum I
• NURS 623 – Adult/Gerontology Health Care II
• NURS 624 – Adult/Gerontology Nursing Practitioner Practicum II
• NURS 629 – Pediatric/Family Health Care
• NURS 630 – Pediatric/Family Nurse Practitioner Practicum
• NURS 635 – Curriculum Development and Evaluation in Nursing Education
• NURS 640 – Adult/Gerontology Acute Care Diagnosis and Management I

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• NURS 641 – Adult/Gerontology Acute Care Nurse Practitioner Practicum I
• NURS 642 – Adult/Gerontology Acute Care Diagnosis and Management II
• NURS 643 – Adult/Gerontology Acute Care Nurse Practitioner Practicum II
• NURS 644 – Adult/Gerontology Acute Care Diagnosis and Management III
• NURS 645 – Adult/Gerontology Acute Care Nurse Practitioner Practicum III
• NURS 650 – Health Promotion of the Pediatric Population
• NURS 651 – Pediatric Assessment and Diagnosis I
• NURS 652 – Pediatric Assessment and Diagnosis Practicum I
• NURS 653 – Pediatric Assessment and Diagnosis II
• NURS 654 – Pediatric Assessment and Diagnosis Practicum II
• NURS 660 – Psychopharmacology and Advanced Mental Health
• NURS 661 – Psychiatric Mental Health Diagnosis and Management I
• NURS 662 – Psychiatric Mental Health Diagnosis and Management Practicum I
• NURS 663 – Psychiatric Mental Health Diagnosis and Management II
• NURS 664 – Psychiatric Mental Health Diagnosis and Management Practicum II
• NURS 665 – Psychiatric Mental Health Diagnosis and Management III
• NURS 667 – Psychiatric Mental Health Diagnosis and Management Practicum III
• NURS 670 – Healthcare Human Resources and Organizational Behavior
• NURS 671 – Healthcare Financial Management
• NURS 672 – Quality and Patient Safety
• NURS 673 – Communication Dynamics in Healthcare
• NURS 674 – Population Health in the Evolving Healthcare System
• NURS 675 – Legal and Ethical Issues in Health Care Leadership
• NURS 676 – Knowledge Management
• NURS 677 – Innovative Leadership Project
• NURS 697 – Special Studies
• NURS 700 – Principles of Epidemiology And Biostatistics
• NURS 701 – Foundations of Clinical Scholarship
• NURS 702 – Integrating and Synthesizing Research
• NURS 703 – Ethics For Advanced Nursing Practice
• NURS 704 – Quality and Patient Safety in Advanced Nursing Practice
• NURS 705 – Clinical Inquiry I
• NURS 706 – Clinical Inquiry II
• NURS 707 – Clinical Inquiry III
• NURS 708 – Organizational and Systems Leadership
• NURS 709 – Advanced Health Policy
• NURS 710 – Graduate Statistics

NURS 640 Global Health Policy and Delivery essay assignment

NURS 640 – Research for Evidence Based Nursing essay assignment

List those questions you would ask in order to develop the HPI for this patient.  Questions should follow a logical order (remember OLD CART?)

As part of your HPI, you find the need to ask for some further information:

PMH:

What questions regarding her PMH would you ask?

PSH:

If you have any past surgical history questions, list them here:

Social history:

If you have any social history questions, ask them here?

 

Medication: (5 points)_________points earned

You may have already asked about her meds in the HPI, but if not, what questions might you have about her medications?

Physical Examination: (10 points)__________points earned

Describe your approach to the PE here.  Discuss (in an organized, head to toe fashion) what you would be looking for and why.  Don’t forget that you can re-do or add any missing components from the VS as part of your PE.

This is not intended to be a complete physical.  You should be doing a problem focused exam.  Please  describe what PE components you would include and what you would be looking for when examining this patient.  You can do as much of a PE on this patient as you think you may need.

Differential diagnosis (list the 3 most likely diagnosis for this patient) (10 points)

__________points earned

For each of the following diagnosis describe why you chose the diagnosis and briefly describe the underlying pathophysiology of the problem.  Provide references where needed.

#1.Pathophysiology:

#2.Pathophysiology:

#3.Pathophysiology:

Diagnostic plan:  (10 points)

___________points earned

In order to rule in/out your differential diagnosis above, describe your diagnostic plan (list each test and describe why you would order the test) and provide references where necessary.

(In your diagnostic and treatment plans, if you feel you would have the need to discuss this patient with any other providers in the office, you can list that as part of your plan.  You do not need to consult with anyone, but you can list that as an option if it is something you are considering).

1.

2.

3.

(you can list as many tests here as you will need—you are not limited to three)

 

Treatment plan:  (5 points)__________points earned

For your primary differential diagnosis (#1) list the items in your treatment plan and why you are choosing each one.  Provide references where necessary.  You do not have to provide a reference for every referral you may make, but if you plan on treating with medication, provide a reference or the guideline which you are following in order to determine which medication to use.

1.

2.

3

(you can list as many treatments as you will need, you are not limited to three)

 

Follow up plan:  (5 points)__________points earned

In keeping with differential diagnosis #1, describe any instructions you are giving to the patient (when to call, any “red flags” for which the patient should call or be seen).  Describe when you would ask this patient to see you again.

1.

2.

3.

(you can list as many follow up instructions as you may need, you are not limited to three)

Health promotion: (5 points)__________points earned

Because T.P. is a new patient you do not have any medical records to review. Which wellness test/health promotion activities would you recommend to this patient at her follow up?  (provide references).

Number and list them here:

References (create an APA style reference page at the end your case study) (5 points)

__________points earned

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