Final Case Analysis
Description
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The final case analysis allows the student to demonstrate a thorough but directed clinical history, with initial hypothesis generation and subsequent testing through specific questioning, selection of a primary diagnosis and differential diagnoses in order of likelihood, physical examination directed at gathering further data necessary to confirm or refute the hypotheses, thoughtful and critical selection of investigations to gather additional data such as appropriate diagnostic studies and implementation of a targeted and rationalized management plan that considers the holistic patient and includes appropriate medication selection.
Case
Mrs A is a 58-year-old, Asian American Female who presents with chest discomfort described as pressure under the sternum. The pressure appears after she goes up a flight of steps, it resolves with rest. She has a history of Hypertension, Hyperlipidemia, Hypothyroidism, Diabetes Mellitus Type II and reports she can not feel her feet. She was last seen in the clinic one year ago. She has no current medications available. Se states she ran out of everything except metformin a few months ago. She has no insurance. She is currently unemployed. Her BMI is 28, her B/P is 162/090
Complete the final assignment with a page limit of 8-10 pages (Excluding Title, Reference, and Appendices). Utilize APA format. It is expected that there will be at least five current evidence based sources in this scholarly paper.
|
Competency |
10 points |
8 points |
6 points |
0 points |
|
Thorough directed clinical history |
Includes the ROS, PMH, PSH, and Social history in discussion of clinical history |
Discusses clinical history but misses one important consideration (ROS, PMH, PSH, and Social history) |
Discusses clinical history but misses two important consideration (ROS, PMH, PSH, and Social history) |
Content not presented, No submission |
|
Evidence-supported primary hypothesis for a differential diagnosis |
Develops an evidence-supported primary hypothesis for a differential diagnosis |
Omits the primary diagnosis or the scientific base |
Omits the identification of the most likely diagnosis instead generates a list of potential diagnoses |
Content not presented, No submission |
|
Alternate hypotheses (differential diagnoses) and supports with evidence |
Develops a list of five alternate hypotheses (differential diagnoses) and supports with evidence |
Content not presented, No submission |
||
|
Physical assessment signs that support each differential diagnosis presented |
Describes physical assessment signs that support each differential diagnosis presented |
Describes physical assessment signs that support most (4) differential diagnosis presented |
Describes physical assessment signs that support some Less than 4 differential diagnosis presented |
Content not presented, No submission |
|
Prescribes diagnostic studies to evaluate hypotheses. Includes the specificity and sensitivity of each study |
Prescribes diagnostic studies to evaluate all hypotheses. Includes the specificity and sensitivity of each study |
Prescribes diagnostic studies to evaluate most (4) hypotheses. Includes the specificity and sensitivity of each study |
Prescribes diagnostic studies to evaluate all hypotheses. Does not include specificity and sensitivity for tests |
Content not presented, No submission |
|
Patient and family inclusion to assist in diagnostic error avoidance |
Thoroughly discusses patient and family inclusion to assist in diagnostic error avoidance |
Discusses patient inclusion without any family or community discussion or strategy presentation |
Discusses generalized importance of Patient and family inclusion but provides no planned strategy |
Content not presented, No submission |
|
Health IT resources to improve diagnostic accuracy |
Describes Health IT resources to improve diagnostic accuracy and provides evidence-based support of implementation |
Describes Health IT resources to improve diagnostic accuracy but no evidentiary support |
Speaks in general about Health IT without discussion of its impact on diagnostic accuracy or evidence-based implementation |
Content not presented, No submission |
|
Pharmacologic interventions appropriate to each differential diagnosis |
Chooses pharmacologic interventions appropriate to each differential diagnosis |
Chooses pharmacologic interventions appropriate to most (4) differential diagnoses |
Chooses pharmacologic interventions appropriate to some (less than 4) differential diagnoses |
Content not presented, No submission |
|
Describes social needs, embracing culture, diversity and equity to suggest resources |
Describes social assessment needs, culture diversity and equity and resources |
Omits one: Social assessment, culture, diversity, equity, OR resources |
Omits two: Social assessment, culture, diversity, equity, OR resources |
Content not presented |
|
10 |
8 |
6 |
0 |
|
|
APA, grammar, spelling, and punctuation compliance |
No errors in APA, grammar, spelling, or punctuations |
One to three errors in APA, grammar, spelling, or punctuation. |
Four to six errors in APA, grammar, spelling, or punctuation. |
Seven or more errors in APA, spelling, or punctuation. |
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