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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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