The Case Study is something that you may not have encountered before, a case with

The Case Study is something that you may not have encountered before, a case with an unusual presentation, or a case that was complicated with many layers which impacted the overall treatment plan. You will include a SOAP note from this encounter. You may use the note you wrote in your clinical encounter as long as this includes the main subsections of the SOAP note format required by UNCG SON. Please add your self critique of how you diagnosed and treated the patient, and what you would have done differently, or added once you completed the encounter. Criteria Points possible Succinct introduction of the patient in 1-2 sentences using semantic qualifiers For example, rather that stating it is a patient with chest pain, state: 55-year-old man with a 2-week history of sub-sternal, burning chest pain worsening during exercise. 10 Completion of subjective information Address all of the OLDCARTS information, allow for class questions and lead a discussion on physical exam decisions 10 Objective exam: Pertinent positives and negatives 10 Lead discussion on appropriate diagnostic studies and present study results 10 Lead discussion on differential diagnosis 10 Discuss most likely differential diagnosis and why Match illness script of the diagnosis and the patient 10 Management options Discuss which management options are possible, including referrals and discuss why you chose a certain option. Include evidence-based treatment 10 Lessons learned: Discuss what you learned in this specific case. You may include health disparities, pathophysiology of the disease process, evidence-based practice, and/or appropriate referral. 20 This should be done in the following SOAP Note Format with self-critiques via the assignment links in Canvas. Follow the SOAP note/self-critique template below with point allocations. The SOAP note/self-critiques will be graded using a rubric. The purpose of the SOAP self-critique assignment is to develop self-awareness of areas where you need to improve. None of us is perfect, and you will likely still have areas where you will omit something from the history or PE or miss a diagnosis. The self-critique area is where you identify areas where you can improve your skills. In addition, completing the SOAP note allows you to demonstrate to us your skills in diagnostic reasoning and clinical decision making as well as in written communication. Using the guideline below, evaluate and write a brief self-critique for each section of the SOAP note. SOAP note with Self-Critique Points Possible S: Chief complaint and history components: At the end of this section, write a brief review and analysis. Make sure you highlight the patient representation. Did you: · Include all the elements of the HPI and/or other appropriate history areas? · Was the ROS appropriate for the HPI and differential diagnoses? Anything missing? · Evaluate the patient’s Rx and OTC medications: Identify any problems such as over self-medicating, over-prescribing, drug-drug or drug-herb interactions, and contraindications? · List patient’s allergies? · Use appropriate medical terminology? · Use and cite appropriate EB references to support your thinking and rationale. · Consider Social determinants of health. Perhaps you did not consider that at the time, but in hindsight, you can explore how SDOH affected this client’s ability to adhere to a regimen. Discuss that in this section. 25 O: Focused PE and pertinent lab/diagnostic data: At the end of this section, write a brief review and analysis. · Was the physical exam and labs appropriate for the HPI & differential diagnoses? · Was there an ROS or advanced physical assessment technique that you missed/could have used to assist with ruling in/out a differential diagnosis? · Did the physical findings support your differential diagnoses? Identify pertinent positives/negatives? · Document diagnostic test results? · Use appropriate medical terminology? · Use and cite appropriate EB references to support your thinking and rationale. 25 A: List the actual diagnoses that you addressed in this visit with ICD-10 codes in the form of illness scripts. Do NOT list all the diagnoses in the problem list. Make sure that you are listing actual diagnoses and not just symptoms. For example, shortness of breath (SOB) is a symptom. Even though it has an ICD-10 code, it is not an actual medical diagnosis. What is causing the SOB? I need to know that you have thought through all the possible diagnoses that could be causing the SOB and come up with a working diagnosis. After the list of actual diagnosis(es), write a brief review and analysis. Did you: · Identify any diagnosis(es) you forgot to document for the visit but did address? · List 3 or more prioritized and appropriate differential diagnoses? · Include a “can’t miss” diagnosis and how that was ruled out. · · Do you agree with the actual diagnosis(es)? Explain why the actual dx is correct and the differentials are incorrect. If you disagree with the actual diagnosis(es), present evidence to support your diagnostic reasoning. · Use and cite appropriate EB references to support your thinking and rationale. 20 P: Management plan: diagnostic tests, complete prescribing information for OTCs and prescription medications, patient/family education, consultations, referrals, follow-up plan: After the management plan, write a brief review and analysis. Explain if you agree or disagree with the plan and cite EB resources to explain your reasoning. Include the following in the self-critique: · Does the plan follow established EB guidelines? If not, explain how the plan deviates and the rational for this action. Using guidelines, EB resources, evaluate the appropriateness of the plan. · Explain why you chose the medication(s) you ordered? What other treatment options could have been used? · Did you include all prescribing information for OTC and Rx medications? Identify if any element is missing. · Appropriate diagnostic test(s) ordered? Did the test results appropriately inform the plan of care? · Follow-up plan appropriate? · Again, consider SDOH in this section. Are you ordering a diagnostic test that a patient cannot afford or that is not in line with his/her belief system/religious or cultural practices? Discuss here. 25

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