Choose one patient that you have cared for in the clinical setting between the a

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Choose one patient that you have cared for in the clinical setting between the a

Choose one patient that you have cared for in the clinical setting between the ages of 10-18 years old for an episodic/sick visit.
The episodic case studies should include the following:
CC/reason for visit
Subjective data
·      Informant and reliability
·      OLDCARTS
·      ROS
·      Medications currently taking
·      Allergies
·      Any pertinent PMH including surgeries, family history and social history
Objective data
·      V/S, including ht, wt, BMI/percentiles (include implications/interpretation)
·      Physical exam – include all parts of the exam that were performed in clinical.  Document as you would in a chart.
·      POC testing completed in the office
Diagnosis (including a 2-3 sentence pathophysiology of the dx)
·      Document the primary diagnosis that was used for treatment.  Include a brief pathophysiology with pertinent positives/negatives
·      Include 3 differential diagnoses with the pathophysiology for each diagnosis and pertinent positives/negatives
·      Include the ICD-10 information for all diagnoses
Plan of Care (include rationale for each of the following)
·      Medications – Include ALL medications to be continued, ordered or discontinued with rationale.  Include the concentration of medication ordered along with the dosing.
(ex. Amoxil 90mg/kg, 400mg/5cc.  Ordered 5cc BID X 10 days)
·      Testing/labs ordered
·      Education provided (Include medications, lifestyle, etc.)
·      Include one Healthy People 2030 Objective appropriate for this patient
·      Referrals/resources when appropriate
·      Follow up recommended to the clinic and to school
Reflection – answer each question separately and thoroughly
Data collection:
1.        Did you agree or disagree with the subjective and objective data that was assessed?
2.        Why/why not?
3.        What would you do differently as the FNP?
Assessment:
1.        Did you agree or disagree with the primary diagnosis?
2.        Why/why not?
3.        If not, what would you have chosen for the primary diagnosis and why?
Plan of Care:
1.        Did you agree or disagree with the plan of care?
2.        Why/why not?
3.        What would you do differently as the FNP?
4.        Document the scholarly sources or EBP guidelines that support this plan of care.
References/citations
·      According to APA guidelines (7th edition)
I have attached a copy of a sample case study to guide you. Please do not use PubMed/StatPearls. References should be within 5 years. Thank you.

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