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CLINICAL CASE

Open Posted By: highheaven1 Date: 12/10/2020 Graduate Dissertation & Thesis Writing

Clinical Case Presentations: (25% 0f Grade)
Students must post one interesting case . The case should be an unusual diagnosis, or a complex case that required in-depth evaluation on the student’s part. The case should be posted in the SOAP format, with references for the patient diagnosis, differential diagnoses (there should be at least 3), and the treatment plan.  The posting does not have to be written in APA format, but should be written with correct spelling and grammar. References should be in APA format. The selected references should reflect current evidence – dated within the past 5 years.

Clinical Case Grading Criteria: The evaluation of the presentation is based on the following:

Criteria

Chief Complaint & pertinent history 10 points


1)Pertinent exam and diagnostics 10 points


2)Working diagnosis with supporting criteria 5 points


3)Management plan 5 points


4)Epidemiological data - cited from literature 10 points


5)Evidenced based rationale for treatment (literature based) 10 points


6)Analysis of self-care and family issues r/t diagnosis and treatment plan 20 points


7)Evaluation parameters to be used (or were used) to determine outcomes 10 points


8)Identify major "lessons learned" and how it may affect your future practice 20 points


FINAL: Total 100 points


-PLEASE NO PLAGIARISM

- REQUIRE APA FORMAT JUST IN REFERENCES.

-Guide by the upload EXAMPLE FOR FORMAT, AND Just ADD THE INFORMATION I wrote in this box, FROM 1 TO 8, the rest can be REMOVED. GUIDE FOR FORMAT.

-SELECT AN INTERESTING DIAGNOSIS , THAT ALLOW YOU TO DEVELOP AN IMPORTANT CASE.

I NEED THE WORK FOR TUESDAY 10/13/2020


Category: Business & Management Subjects: Business Communication Deadline: 12 Hours Budget: $120 - $180 Pages: 2-3 Pages (Short Assignment)

Attachment 1

Patient Initials:

Pt. Encounter Number:

Date:

Age:

Sex:

Allergies: Advanced Directives:

SUBJECTIVE

CC: Reason given by the patient for seeking medical care “in quotes”

HPI: Describe the course of the patient’s illness: Onset: Location: Duration: Characteristics: Aggravating Factors: Relieving Factors: Treatment:

Current Medications: (List with reason for med)

PMH Medication Intolerances: Chronic Illnesses/Major traumas Screening Hx/Immunizations Hx: Hospitalizations/Surgeries: “Have you ever been told that you have diabetes, HTN, peptic ulcer disease, asthma, lung disease, heart disease, cancer, TB, thyroid problems, kidney problems, or psychiatric diagnosis?”

Family History Does your mother, father, or siblings have any medical or psychiatric illnesses? Is anyone diagnosed with: lung disease, heart disease, HTN, cancer, TB, DM, or kidney disease?

Social History Education level, occupational history, current living situation/partner/marital status, substance use/abuse, ETOH, tobacco, and marijuana. Safety status

OBJECTIVE

Weight BMI

Temp

BP

Height

Pulse

Resp

Oxygen Saturation

Lab Tests

Urinalysis—pending Urine culture—pending Wet prep—pending

Special Tests

Diagnosis

  • • Primary Diagnosis- Include at least three diagnoses ♣ Evidence for primary diagnosis should be documented in your Subjective and Objective exams. • Secondary Diagnosis- if apply, chronic diseases can be included as secondary diagnosis o Differential Diagnoses- provide at least three differential diagnosis supported by signs and symptoms explaining why these are not your primary diagnosis PLAN including education o Plan: ♣ Further testing ♣ Medication ♣ Education ♣ Nonmedication treatments ♣ Referrals ♣ Follow-up visits

References (minimum 3 references) APA FORMAT JUST REFERENCES