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Mrs. Wong, a 59-year-old Asian female, presents to the office for a planned 3 month follow up visit for her recently diagnosed right knee arthritis.

NR601 W5 Case Study

Mrs. Wong, a 59-year-old Asian female, presents to the office for a planned 3 month follow up visit for her recently diagnosed right knee arthritis. She is experiencing less knee pain and increased mobility with the treatment plan but reports some new concerns today. She reports that she has been experiencing increasing fatigue for about the last 2 months. She is also gaining weight since menopause 4 years ago. She has a health club membership and attends twice a week. She walks on the treadmill at least 30 minutes as you directed and lifts light weights but she has not lost any weight, in fact she has gained 4 pounds. She doesn’t understand what she is doing wrong. She reports that exercise seems to make her even more hungry and thirsty, which is not helping her weight loss. She requests evaluation as to why she is so tired and get some weight loss advice.

Current medications: Tylenol 500 mg 2 tabs in AM for knee pain. Daily multivitamin and
turmeric. USES CBD oil for her knee, find it helps.
PMH: Has right knee arthritis diagnosed 3 months ago. Had German measles as a child.
Vaccinations up to date. Colonoscopy WNL 4 years- repeat in 10 years
GYN hx: G1 P1: daughter delivered@37 weeks, wt 8lbs 15oz. LMP 4 years ago. ASCUS pap
1998, all further paps WNL. Mammogram last year BI-RADS 1.
FH: parents deceased, child alive, well. No siblings.
SH: Divorced. works from home as an administrative assistant., 1-2 glasses wine one or two
times a week. Former smoker, quit 12 years ago.
Allergies: allergic to Bactrim, cats and pollen. No latex allergy
Vital signs: BP 112/76; pulse 80, regular; respiration 16, regular
Height 5’1.5”, weight 165 pounds

General: female in no acute distress. Alert, oriented and cooperative.
Skin: warm dry and intact. No lesions noted.
HEENT:. Eyes without exudate, sclera white. Wears contacts. Tympanic membranes gray and intact with light reflex noted. Pinna and tragus nontender. Nares patent without exudate. Oropharynx moist without erythema. Teeth in good repair, no cavities noted. Neck supple. Anterior and posterior cervical lymph nontender to palpation. No lymphadenopathy. Thyroid
midline, small and firm without palpable masses.
CV: S1 and S2 RRR without murmurs or rubs.
Lungs: Clear to auscultation bilaterally, respirations unlabored.
Abdomen– soft, round, nontender with positive bowel sounds present; no organomegaly; no abdominal bruits. No CVAT.
Musculoskeletal: full ROM both knees. Nontender to palpation bilaterally. Gait normal.

GU: bladder nontender upon palpation

Assignment Template

Assignment Title

Title page per APA format 

  • This assignment template serves as a paper template to develop the week 5 case study and may not be all inclusive. You must also refer to the assignment rubric for specific requirements for this assignment. Your paper is graded to the rubric requirements. *

Title matches title on title page

The introductory paragraph is written here. Remember to remove all instructions from your paper. These are in red ink.

Assessment

Primary Diagnosisdiagnosis (ICD10 code)

pathophysiologyA brief pathophysiology statement which is no longer that two sentences, paraphrased and includes common signs and symptoms of the diagnosis.Includes citation to an approved source (author, year).Review the Reference Guidelines for FNP Case Study document.This applies to all sections of this paper.

pertinent positive findingsincludes citation to an approved source (author, year).Review the Reference Guidelines for FNP Case Study documents.This applies to all sections of this paper.

pertinent negative findingsincludes citation to an approved source (author, year).Review the Reference Guidelines for FNP Case Study documents.This applies to all sections of this paper.

rationale for the diagnosisincludes a brief 1-2 sentence statement, which links the subjective and objective case study findings including provided lab data and interpretation of the labs. Include a statement linking those lab results to your ADA guideline reference.  Includes citation to the ADA guideline used to determine this diagnosis.

Secondary Diagnosisdiagnosis (ICD10 code)

            *You can have more than one secondary diagnosis. A minimum is required. Secondary diagnoses are additional diagnoses you have identified from the exam, lab findings today or the PMH*

Pathophysiology A brief pathophysiology statement which is no longer that two sentences, paraphrased and includes common signs and symptoms of the diagnosis (author, year).

pertinent positive findings(author, year).

 pertinent negative findings(author, year).

rationale for the diagnosis-includes a brief 1-2 sentence statement, which links the subjective and objective findings including any provided lab data and interpretation of the diagnostic testing. The rationale includes a citation to a scholarly reference(author, year)

Differential Diagnosisdiagnosis (ICD10 code)

            *You can have more than one differential diagnosis. A minimum of one is required.  Differential diagnoses are additional diagnoses you are considering but require further testing to confirm or rule out based on the appropriate guidelines for the diagnosis. *Additional testing must be listed within the diagnostics section.* 

pathophysiology-A brief pathophysiology statement which is no longer that two sentences, paraphrased and includes common signs and symptoms of the diagnosis (author, year).

rationale for the diagnosis-includes a brief 1-2 sentence statement explaining why you are considering this differential diagnosis. The statement includes the pertinent subjective and objective findings and any diagnostic data, which supports further evaluation. Includes citation (author, year).

Plan

Diagnostics

Lab test(each lab/diagnostic test is listed individually with rationale to follow). Include the timeframe of when the lab is to be drawn. *This is labs or tests you will order in the future, not an explanation of the labs that have already been completed.*

rationale:each rationale contains the EBP statement supporting the necessity of the test and includes the name of the diagnosis which is listed in the assessment section.*If this diagnosis is not listed in the assessment section then it must be added to order the diagnostic testing*. Includes a citation to an approved reference from the Reference Guidelines for FNP Case Study document which supports not only the test but the timing of the lab draw.

Medications*each medication is listed individually with rationale, including the required OTC*

Medication- written in prescription format (see NR 601 Resources)

Rationale.The rationale for each medication includes the diagnosis which is listed in the assessment section and contains the EBP statement supporting the necessity of the medication. If this diagnosis is not listed in the assessment section then it must be added to include any medication. Includes a citation to an approved reference from the Reference Guidelines for FNP Case Study document.

Educationsection includes personalized detailed education on all five (5) subcategories: diagnosis, each medication purpose and side effects, diet, personalized appropriate exercise recommendations and warning sign for diagnosis and medications if applicable. You do not need an introduction paragraph. All education steps are linked to a listed diagnosis, paraphrased, and include a paraphrased EBP rationale.If this diagnosis is not listed in the assessment section then it must be added to include the education content here. Each education section includes a citation to an approved reference from the Reference Guidelines for FNP Case Study document

Diagnoses.

            Includespersonalized detailed education for each diagnosis listed in the assessment section. This includes specific information for this particular client. Education includes a citation to an appropriate reference. No listed education is common knowledge, all statements must include an in text citation to anappropriate reference.

Medications.

includes personalized detailed education for each medication listed in the medication section.Each medication is listed and then explained. No listed education is common knowledge, all statements must include an in text citation to anappropriate reference.

Diet.

            includes personalized detailed education for dietary recommendations as determined by the listed diagnoses in the assessment section. This includes specific dietary information. A referral to cover this requirement is not sufficient. If weight loss is recommended then specific weight loss targets must be included. No listed education is common knowledge, all statements must include an in text citation to anappropriate reference.

Exercise.

            includes personalized detailed education for exercise recommendations as determined by the listed diagnoses in the assessment section..List specific exercises that are appropriate for this patient. No listed education is common knowledge, all statements must include an in text citation to anappropriate reference.

Warning Signs for diagnoses and mediations

            includes personalized detailed education as determined by the listed diagnoses and medications.No listed education is common knowledge, all statements must include an in text citation to anappropriate reference..

Referral

Specialty practice or service (eachreferral is listed individually with rationale to follow)

rationale:each rationale contains the EBP statement supporting the necessity of the referral and includes the name of the diagnosis which is listed in the assessment section. Includes a citation to an approved reference from the Reference Guidelines for FNP Case Study document. Any referrals for the listed primary diagnosis must be cited from the chosen ADA guideline.

Follow up

            Follow up includes a specific time frame ( 1week, 1 month) , not a time range, to return to PCP office for next scheduled appointment. Includes EBP rationale with in text citation. Refer to the rubric for full section requirements.

Medication Cost

See rubric for section requirements.

Conclusion

A summary paragraph

Clinical Chart SOAP note

See rubric instructions for this section. This clinical SOAP note summarizes this case study patient encounter. All included information must be consistent with provided case study information and your assessment and plan listed above. No additional information should be added here.

References

Are listed on a separate page and formatted per APA guidelines.

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