This Assignment will assess your ability to evaluate subjective and objective information in order to arrive at an appropriate diagnosis and treatment plan for the patient.
Hypertension Case Study
C.D is a 55-year-old African American male who presents to his primary care provider with a 2-day history of a headache and chest pressure.
Father died at age 49 from AMI: had HTN
Mother has DM and HTN
Brother died at age 20 from complications of CF
Two younger sisters are A&W
The patient has been married for 25 years and lives with his wife and two children. The patient is an air traffic controller at the local airport. He has smoked a pack of cigarettes a day for the past 15 years. He drinks several beers every evening after work to relax. He does not pay particular attention to sodium, fat, or carbohydrates in the foods he eats. He admits to “salting almost everything he eats, sometimes even before tasting it.” He denies ever having dieted or exercised.
Zyrtec 10 mg daily
States that his overall health has been fair to good during the past year.
Weight has increased by approximately 30 pounds in the last 12 months.
States he has been having some occasional chest pressure and headaches for the past 2 days. Shortness of breath at rest, headaches, nocturia, nosebleeds, and hemoptysis.
Reports some shortness of breath with activity, especially when climbing stairs and that breathing difficulties are getting worse.
Denies any nausea, vomiting, diarrhea, or blood in stool.
Self treats for occasional right knee pain with OTC Ibuprofen.
Denies any genitourinary symptoms.
B/P 190/120, HR 73, RR 18, T. 98.8 F., Ht 6’1”, Wt 240 lbs.
TMs intact and clear throughout
No nasal drainage
No exudates or erythema in oropharynx
Funduscopy reveals mild arteriolar narrowing without nicking, hemorrhages, exudates, or papilledema
Supple without masses or bruits
Mild basilar crackles bilaterally
No murmurs or rubs
Soft and non-distended
No masses, bruits, or organomegaly
Normal bowel sounds
Moves all extremities well
No sensory or motor abnormalities
CN’s II-XII intact
DTR’s = 2+
Muscle tone=5/5 throughout
What you should do:
Before finalizing your work, you should:
Your writing Assignment should:
How to Submit:
Submit your Assignment to the unit Dropbox before midnight on the last day of the unit.
When you are ready to submit your Assignment, select the unit Dropbox then attach your file. Make sure to save a copy of the Assignment you submit.
|Unit 3 assignment grading rubric. Instructors: Enter total available points in cell H2, and values between 0 and 4 in the yellow cells in the Score column.|
|Total available points =||100|
|Content Rubric||Introductory||Emergent||Practiced||Proficient/Mastered||Score||Weight||Final Score|
|0 – 1.9||2 – 2.9||3 – 3.9||4|
|Develop a patient-focused evidence based management plan for this patient.||There is no mention of a management plan for this patient.||The management plan is partially developed but not based on evidence||The management plan is mostly developed but the evidence base is not strong||The management plan is evidence based and completely developed||16%||0.00|
|Pertinent Diagnostics||There is no evidence of any diagnostics||Diagnostic tests poorly addressed||Diagnostics partially addressed||Diagnostics thoroughly addressed||15%||0.00|
|Prepare a detailed, comprehensive, patient-centered education plan.||There is no mention of an education plan||The education plan is included but it is provider-centered vs patient-centered||The education plan is included and is patient-centered but incomplete||The education plan is included and is patient-centered and complete||16%||0.00|
|Cultural and lifestyle considerations||There is no mention cultural and lifestyle considerations||Content poorly addressed||Content addressed but more detail is needed or content inconclusive||Cultural and lifestyle considerations thoroughly addressed||15%||0.00|
|Information on health promotion or health care maintenace needs||Ther is no mention||Content poorly addressed||Health promotion or health care main||Health promotion or health care maintenance needs thoroughly addressed||12%||0.00|
|Describe the developmental educational strategies you will use with this patient||There is no mention of development educational strategies for this education plan||There is some mention of developmental educational strategies but they are not appropriate for the patient’s age and developmental level||The educational strategies are identified and described to great extent but not completely||The educational strategies are well-identified and thoroughly described||12%||0.00|
|Describe the follow-up with specific time lines for this patient. For example, when should he return to the clinic for his next visit?||There is no mention of follow-up for this patient||There is some description for the follow up for this patient but there is not a specific time line identified||There is a description of the time line for follow up for this patient but it is not supported with evidence-based clinical guidelines||There is a description of the time line for follow up for this patient and it is well-supported with evidence-based clinical guidelines||14%||0.00|
|Writing Deduction Rubric (everyone starts with 4’s = no deductions)||Introductory||Emergent||Practiced||Proficient/Mastered||Score||Weight||Final Score|
|Grammar & Punctuation||The overall meaning of the paper is difficult to understand. Sentence structure, subject verb agreement errors, missing prepositions, and missing punctuation make finding meaning difficult.||Several confusing sentences or 1 to 2 confusing paragraphs make understanding parts of the paper difficult, but the overall paper meaning is clear. Many subject verb agreement errors, run-on sentences, etc. cause confusion.||A few confusing sentences make it difficult to understand a small portion of the paper. However, the overall meaning of a paragraph and the paper are intact. There may be a few subject verb agreement errors or some missing punctuation.||There are one or two confusing sentences, but the overall sentence and paragraph meanings are clear. There are a few minor punctuation errors such as comma splices or run-on sentences.||4||35%||1.40|
|Spelling||The many misspelled words and incorrect words choices significantly interfere with the readability.||Many typos, misspelled words, or the use of incorrect words making understanding difficult in a few places.||Some misspelled words or the misuse of words such as confusing then/than. However, intent is still clear.||A few misspelled words normally caught by spellcheckers are present but do not significantly interfere with the overall readability of the paper.||4||35%||1.40|
|Order of Ideas & Length Requirement||Paper has some good information or research, but it does not follow assignment directions and is lacking in overall organization and content.||The order of information is confusing in several places and this organization interferes with the meaning or intent of the paper. However, the paper has a generally discernible purpose and follows assignment directions overall.||The order of information is confusing in a few places and the lack of organization interferes with the meaning or intent of the paper in a minor way.||The overall order of the information is clear and contributes to the meaning of assignment. There is one paragraph or a sentence or two that are out of place or other minor organizational issues. A few sentences may be long and hard to understand. Meets length requirements.||4||20%||0.80|
|APA||There is some attempt at APA formatting and citing. There are one or more missing parts such as the cover page or references list. Citation information may be missing. Citation mistakes make authorship unclear.||This is an attempt use APA formatting and citing. There are both in-text citations and reference listings. Citation information may be missing or incorrect (i.e. Websites listed as in-text or reference citations). There is an attempt to cite all outside sources in at least one place. Authorship is generally clear.||There is an overall attempt at APA formatting and citation style. All sources appear to have some form of citation both in the text and on a reference list. There are some formatting and citation errors. Citations generally make authorship clear.||There is a strong attempt to cite all sources using APA style. Minor paper formatting errors such as a misplaced running head or margins may occur. Minor in-text citation errors such as a missing page number or a misplaced date may occur. Quotation marks and citations make authorship clear.||4||10%||0.40|
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