The Treatment Plan For The Patient in The Assigned Case Study Essay
Please follow instructions carefully, Case study, instructions, rubric below. I got a terrible grade on my last order because it was incomplete. all the questions need to be answered.
Please use the following case to complete a focused SOAP note. Incorporate answers to the questions into your SOAP write up.
Edwin is a 69-year-old male who comes into the clinic today stating that over the past few days, he has had a fever and chills, cough, and has been quite fatigued. He didn’t take his temperature because he did not have a thermometer but he “felt hot.†He says he is coughing up a little phlegm. He states that it hurts when he takes a deep breath. He also states that his appetite has not been very good. He has been taking Tylenol with minimal relief. He has also been drinking teas to try to break up the phlegm. The Treatment Plan For The Patient in The Assigned Case Study Essay
Edwin is a nonsmoker and non-drinker. He has been very healthy and has no medical problems. He has never had surgery.
On exam, his vital signs are: BP 130/80; P 84; R 14; T 103.2; Pulse ox: 94%.
Exam reveals decreased rales and rhonchi, more pronounced in the left lower lung fields, with increased fremitus and dullness to percussion. Chest x-ray reveals a consolidation in the left lower lobe. This appears to confirm that he has pneumonia.
1Which bacteria is the leading cause of pneumonia and the one that he most likely has?
2What is unusual about this pts history as compared to most pts that are at risk for strep.pneumoniae? The Treatment Plan For The Patient in The Assigned Case Study Essay
3In this type of pneumonia, does the sputum analysis indicate gram positive or negative diplococci? There would also be a large number of _________?
4What other bacteria must be considered?
5What is the best way to identify the pathologic agent?
6Where does the best sputum sample come from?
7When is the best time to get a sputum sample? Why is that the best time?
8 When sending the sputum to the lab, how does the lab determine it is an adequate sample?
9Name four other diagnostics that can be done on this patient to further understand his condition.
10If obtaining blood cultures, how many sets are typically obtained? The Treatment Plan For The Patient in The Assigned Case Study Essay
11When choosing an antibiotic to treat this patient, it is important to try to cover for all pathogens, especially gram-negative organisms. True or false?
12When treating on an outpatient basis, what class of drug should be used for this previously healthy man with no use of antimicrobial therapy within the previous 3 months?
13Although there have been cases of resistance against this class, it is still recommended for pts without risk. Please write out the Rx directions the way with the med and the sig how you would write it for the pt.
14 The choice of antibiotic therapy depends on three important factors. What are they?
15In most cases, improvement is seen within __________ to _________ hours of initiation of antibiotics.
16Should cough medicine be recommended? The Treatment Plan For The Patient in The Assigned Case Study Essay
17Name two patient education points you would share with this patient.
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Name: NRNP_6565_Week6_Assignment_Rubric The Treatment Plan For The Patient in The Assigned Case Study Essay
Grid View
List View
Excellent
90%–100% Good
80%–89% Fair
70%–79% Poor
0%–69%
Create documentation in the Focused SOAP Note Template about the patient in the case study to which you were assigned.
In the Subjective section, provide:
• Chief complaint
• History of present illness (HPI) The Treatment Plan For The Patient in The Assigned Case Study Essay
• Current medications
• Allergies
• Patient medical history (PMHx)
• Review of systems
Points Range:9 (9.00%) – 10 (10.00%)
The response throughly and accurately describes the patient’s subjective complaint, history of present illness, current medications, allergies, medical history, and review of all systems that would inform a differential diagnosis.
Points Range:8 (8.00%) – 8 (8.00%)
The response accurately describes the patient’s subjective complaint, history of present illness, current medications, allergies, medical history, and review of all systems that would inform a differential diagnosis. The Treatment Plan For The Patient in The Assigned Case Study Essay
Points Range:7 (7.00%) – 7 (7.00%)
The response describes the patient’s subjective complaint, history of present illness, current medications, allergies, medical history, and review of all systems that would inform a differential diagnosis, but it is somewhat vague or contains minor innacuracies.
Points Range:0 (0.00%) – 6 (6.00%)
The response provides an incomplete or inaccurate description of the patient’s subjective complaint, history of present illness, current medications, allergies, medical history, and review of all systems that would inform a differential diagnosis. Or, subjective documentation is missing.
In the Objective section, provide:
• Physical exam documentation of systems pertinent to the chief complaint, HPI, and history
• Diagnostic results, including any labs, imaging, or other assessments needed to develop the differential diagnoses
Points Range:9 (9.00%) – 10 (10.00%) The Treatment Plan For The Patient in The Assigned Case Study Essay
The response thoroughly and accurately documents the patient’s physical exam for pertinent systems. Diagnostic tests and their results are thoroughly and accurately documented.
Points Range:8 (8.00%) – 8 (8.00%)
The response accurately documents the patient’s physical exam for pertinent systems. Diagnostic tests and their results are accurately documented.
Points Range:7 (7.00%) – 7 (7.00%)
Documentation of the patient’s physical exam is somewhat vague or contains minor innacuracies. Diagnostic tests and their results are documented but contain minor innacuracies. The Treatment Plan For The Patient in The Assigned Case Study Essay
Points Range:0 (0.00%) – 6 (6.00%)
The response provides incomplete or inaccurate documentation of the patient’s physical exam. Systems may have been unnecessarily reviewed, or objective documentation is missing.
In the Assessment section, provide:
• At least three differentials with supporting evidence. Explain what rules each differential in or out and justify your primary diagnosis selection. Include pertinent positives and pertinent negatives for the specific patient case.
Points Range:23 (23.00%) – 25 (25.00%)
The response lists in order of priority at least three distinctly different and detailed possible conditions for a differential diagnosis of the patient in the assigned case study, and it provides a thorough, accurate, and detailed justification for each of the conditions selected.
Points Range:20 (20.00%) – 22 (22.00%) The Treatment Plan For The Patient in The Assigned Case Study Essay
The response lists in order of priority at least three different possible conditions for a differential diagnosis of the patient in the assigned case study, and it provides an accurate justification for each of the conditions selected.
Points Range:18 (18.00%) – 19 (19.00%)
The response lists three possible conditions for a differential diagnosis of the patient in the assigned case study, with some vagueness and/or inaccuracy in the conditions and/or justification for each.
Points Range:0 (0.00%) – 17 (17.00%)
The response lists two or fewer, or is missing, possible conditions for a differential diagnosis of the patient in the assigned case study, with inaccurate or missing justification for each condition selected. The Treatment Plan For The Patient in The Assigned Case Study Essay
In the Plan section, provide:
• A detailed treatment plan for the patient that addresses each diagnosis, as applicable. Includes documentation of diagnostic studies that will be obtained, referrals to other healthcare providers, therapeutic interventions, education, disposition of the patient, and any planned follow up visits.
• A discussion related to health promotion and disease prevention taking into consideration patient factors, PMH, and other risk factors.
• Reflections on the case describing insights or lessons learned.
Points Range:27 (27.00%) – 30 (30.00%)
The response thoroughly and accurately outlines a treatment plan for the patient that addresses each diagnosis and includes diagnostic studies neeed, referrals, therapeutic interventions, patient education and disposition, and planned follow-up visits. A thorough and accurate discussion of health promotion and disease prevention related to the case is provided. Reflections on the case demonstrate strong critical thinking and synthesis of ideas.
Points Range:24 (24.00%) – 26 (26.00%) The Treatment Plan For The Patient in The Assigned Case Study Essay
The response accurately outlines a treatment plan for the patient that addresses each diagnosis and includes diagnostic studies neeed, referrals, therapeutic interventions, patient education and disposition, and planned follow-up visits. An accurate discussion of health promotion and disease prevention related to the case is provided. Reflections on the case demonstrate critical thinking.
Points Range:21 (21.00%) – 23 (23.00%)
The response somewhat vaguely or inaccurately outlines a treatment plan for the patient. The discussion on health promotion and disease prevention related to the case is somewhat vague or contains innaccuracies. Reflections on the case demonstrate adequate understanding of course topics. The Treatment Plan For The Patient in The Assigned Case Study Essay
Points Range:0 (0.00%) – 20 (20.00%)
The response does not address all diagnoses or is missing elements of the treatment plan. The discussion on health promotion and disease prevention related to the case is vague, innaccurate, or missing. Reflections on the case are vague or missing.
Provide at least three evidence-based, peer-reviewed journal articles or evidenced-based guidelines that relate to this case to support your diagnostics and differentials diagnoses. Be sure they are current (no more than 5 years old) and support the treatment plan in following current standards of care.
Points Range:9 (9.00%) – 10 (10.00%)
The response provides at least three current, evidence-based resources from the literature to support the treatment plan for the patient in the assigned case study. Each resource represents the latest in standards of care and provides strong justification for treatment decisions.
Points Range:8 (8.00%) – 8 (8.00%) The Treatment Plan For The Patient in The Assigned Case Study Essay
The response provides at least three current, evidence-based resources from the literature to support the treatment plan for the patient in the assigned case study. Each resource represents current standards of care and supports treatment decisions.
Points Range:7 (7.00%) – 7 (7.00%)
Three evidence-based resources are provided to support treatment decisions, but may not represent the latest in standards of care or may only provide vague or weak justification for the treatment plan.
Points Range:0 (0.00%) – 6 (6.00%)
Two or fewer resources are provided to support treatment decisions. The resources may not be current or evidence based or do not support the treatment plan. The Treatment Plan For The Patient in The Assigned Case Study Essay
Written Expression and Formatting – Paragraph Development and Organization:
Paragraphs make clear points that support well-developed ideas, flow logically, and demonstrate continuity of ideas. Sentences are carefully focused–neither long and rambling nor short and lacking substance. A clear and comprehensive purpose statement and introduction are provided that delineate all required criteria.
Points Range:5 (5.00%) – 5 (5.00%)
Paragraphs and sentences follow writing standards for flow, continuity, and clarity.
A clear and comprehensive purpose statement, introduction, and conclusion are provided that delineate all required criteria. The Treatment Plan For The Patient in The Assigned Case Study Essay
Points Range:4 (4.00%) – 4 (4.00%)
Paragraphs and sentences follow writing standards for flow, continuity, and clarity 80% of the time.
Purpose, introduction, and conclusion of the assignment are stated, yet are brief and not descriptive.
Points Range:3 (3.00%) – 3 (3.00%)
Paragraphs and sentences follow writing standards for flow, continuity, and clarity 60%–79% of the time.
Purpose, introduction, and conclusion of the assignment are vague or off topic.
Points Range:0 (0.00%) – 2 (2.00%)
Paragraphs and sentences follow writing standards for flow, continuity, and clarity < 60% of the time. The Treatment Plan For The Patient in The Assigned Case Study Essay
No purpose statement, introduction, or conclusion were provided.
Written Expression and Formatting – English Writing Standards:
Correct grammar, mechanics, and proper punctuation
Points Range:5 (5.00%) – 5 (5.00%)
Uses correct grammar, spelling, and punctuation with no errors.
Points Range:4 (4.00%) – 4 (4.00%)
Contains 1 or 2 grammar, spelling, and punctuation errors.
Points Range:3 (3.00%) – 3 (3.00%)
Contains several (3 or 4) grammar, spelling, and punctuation errors.
Points Range:0 (0.00%) – 2 (2.00%)
Contains many (≥ 5) grammar, spelling, and punctuation errors that interfere with the reader’s understanding.
Written Expression and Formatting – The paper follows correct APA format for title page, headings, font, spacing, margins, indentations, page numbers, running heads, parenthetical/narrative in-text citations, and reference list. The Treatment Plan For The Patient in The Assigned Case Study Essay
Points Range:5 (5.00%) – 5 (5.00%)
Uses correct APA format with no errors.
Points Range:4 (4.00%) – 4 (4.00%)
Contains 1 or 2 APA format errors.
Points Range:3 (3.00%) – 3 (3.00%)
Contains several (3 or 4) APA format errors.
Points Range:0 (0.00%) – 2 (2.00%)
Contains many (≥ 5) APA format errors.
Name:NRNP_6565_Week6_Assignment_Rubric The Treatment Plan For The Patient in The Assigned Case Study Essay