Case Study – Part 2
You ordered a CXR and spirometry at the previous visit and he returns today to review the results. Physical exam and symptoms are unchanged since last visit. Vital signs at this visit are: Temp-98.3, P-68, RR-20, BP 152/90, Height 68.9in., Weight 258 pounds, O2sat 94% on RA
CXR Result:
No acute infiltrates or consolidations are seen. Cardiac and mediastinal silhouettes are normal. No hilar enlargement is evident. Osseous thorax is intact.
Spirometry Results:
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Pre-Bronchodilator
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Post-Bronchodilator
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Predicted
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Actual
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%Predicted
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Actual
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% Predicted
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% Change
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FVC (L)
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4.52
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3.01
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67
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3.08
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68
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2
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FEV1 (L)
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3.40
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1.58
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46
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1.60
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47
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1
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FEV1/FV
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.75
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.52
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—
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.52
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—
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0
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Requirements/Questions:
- What is your primary (one) diagnosis for this patient at this time? (support the decision for your diagnosis with pertinent positives and negatives from the case)
- Identify the corresponding ICD-10 code.
- Provide a treatment plan for this patient’s primary diagnosis which includes:
- Medication*
- Any additional testing necessary for this particular diagnosis*
- Patient education
- Referral
- Follow up
- Provide an active problem list for this patient based on the information given in the case.
- Are there any changes that you would also make to this patient’s overall treatment plan at this time? Must provide an EBP argument for each treatment or testing decision.
*If part of the plan does not warrant an action, you must explain why. ALL medication and testing decisions (or decisions not to treat with medication or additional testing) MUST be supported with an evidence-based practice (EBP) argument. Over-the-counter (OTC) and RXs must be written in full as if handing a script to the patient in the office.
Over-the-counter (OTC) and RXs must be written in full as if handing a prescription to the patient in the office.
Example:
Amoxicillin 500 mg capsule
1 tab po BID q 10 days
Disp #20 no refills
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DISCUSSION CONTENT
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Category
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Points
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%
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Description
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Application of Course Knowledge
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15
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30%
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- Student chooses one appropriate diagnosis for the patient; AND
- Diagnosis is supported with strong pertinent positive and negative subjective and objective data from parts 1 & 2; AND
- The ICD code for the diagnosis is correct; AND
- Treatment plan for primary diagnosis includes medication, additional testing, patient education, and referral; AND
- Prescription and OTC medications are written appropriately as a RX and all components are correct; AND
- Treatment decisions (medication, additional testing, referrals) are supported with appropriate EBP arguments; AND
- An accurate problem list is presented based on case information; AND
- Student discusses changes (or not) to the overall treatment plan for the patient for pertinent issues; AND
- An appropriate F/U plan is provided
(9 critical elements)
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Support from Evidence-Based Practice (EBP)
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15
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30%
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- Discussion post is supported with appropriate, scholarly sources AND
- Sources are published within the last 5 years (unless the most current CPG is used) AND
- A reference list is provided with in-text citations that match AND
- All testing decisions are fully supported with an appropriate EBP argument
(4 critical elements)
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Interactive Dialogue
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10
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20%
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- Student provides a substantive* response to at least one topic-related post of a peer AND
- Includes evidence from appropriate scholarly sources AND
- Provides a reference list which match in-text citations AND
- Student responds to all direct faculty questions
(4 critical elements)
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Total CONTENT Points= 40 pts
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DISCUSSION FORMAT
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Category
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Points
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%
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Description
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Organization
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5
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10%
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- Case study response is presented in a logical format, AND
- Responses are in sequence with the numbered questions AND
- The case study response is understandable and easy to follow AND
- All responses are relevant to the case topic
(4 critical elements)
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Grammar, Syntax, Spelling & Punctuation
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5
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10%
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Discussion post has minimal grammar, syntax, spelling, punctuation, or APA format errors*
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Total FORMAT Points= 10 pts
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DISCUSSION TOTAL= 50 pts
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