Scenario: Mr. C, a 64 year-old faculty member teaching computer science, presents with headache, weakness, and numbness on his left extremities. He’s by himself and a little confused, so his history is “sketchy.” CC: “I had these problems this morning. I then seemed to improve, and then got worse. Now I’m getting scared.” Past medical history: Hypertension, possible transient ischemic attacks s last year per verbal history (patient was on vacation). Has been taking ASA 81 mg and amlodipine (Norvasc) 10 mg daily. Physical exam: Blood pressure, 162/96; respiration rate, 26/min. Patient awake but confused, left foot slightly externally rotated, difficulty walking, bilateral high-pitched carotid bruits, decreased sensation in left lower extremity. Questions to think about when writing paper per instructor but not mandatory- criteria given is straight from rubric and should be used as the paragraph headings. 1. What additional subjective data do you think the patient will share? 2. What additional objective data will you be assessing for? 3. What National Guidelines are appropriate to consider? What level of evidence supports these guidelines? 4. What tests will you order? 5. Will you be looking for a consult? 6. What are the medical and nursing diagnoses? 7. Are there any legal/ethical considerations? 8. What is your plan of care? medical nursing complementary therapies 9. Are there any Healthy People 2020 objectives that you should consider? 10. Using the Circle of Caring, what or who else should be involved to truly hear the patient’s voice, getting him and the family involved in the care to reach optimal health? 11. What additional patient teaching is needed? 12. What billing codes would you recommend? Criteria from rubric: Assessment Develops and demonstrates a clear & precise assessment plan supported with professional literature and includes objective and subjective data. Guidelines/Evidence Thoroughly describes all relevant practice guidelines. Clearly defines and delineates the levels of evidence that support the guidelines. Diagnostics Clearly describes all appropriate diagnostics (including sensitivity and specificity). Clearly differentiates the difference between a positive and a negative finding and APN considerations Treatment Plan Develops and provides a clearly written set of orders inclusive of all essential elements in a treatment plan Evaluation Develops and demonstrates a clear & precise evaluation plan for the next office visit inclusive of data that will indicate no change necessary in plan or changes necessary in the plan Healthy People 2020/Health Promotion Develops and demonstrates a clear & precise desсrіption of the Healthy People 2020 goals and specifically relates one goal to current case. Patient/Family Teaching Develops and demonstrates a clear & precise educational plan for the patient and family. Billing Discusses all levels of billing that apply to the case and most likely appropriate level for first visit and one follow up visit What billing codes would you recommend? Follow up Develops a follow up plan that specifically identifies the data that will need to be reviewed during the follow up visit. (This may function as communication to the team…i.e. check BP, cholesterol, and EKG next visit)
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