This assignment is about creating a case study that includes subjective and objective information, assessment, and a plan for a patient, using evidence-based practice and appropriate medical terminology and references.

GUIDELINES FOR CASE STUDY Required elements of the case study: All papers are to be type written, double spaced, with pages numbered. Please write course name and number, your name, and date clearly on materials submitted. Use American Psychological Association (APA) style 6th edition including paper format and references. Points may be deducted for multiple spelling, grammar, format and typing errors. Subjective State the patient’s chief complaint, reason for visit and/or the problem for which you are providing follow-up for. All symptoms related to the problem are described using the following cue descriptive categories: 1) Precipitating/alleviating factors (including prescribed and/or self-remedies and their effect on the problem). Associated symptoms Quality of all reported symptoms including the effect on the patient’s lifestyle Temporal factors (date of onset, frequency, duration, sequence of events) Location (localized or generalized? does it radiate?) Sequelae (complications, impact on patient and/or significant other) Severity of the symptoms Past Medical History including immunizations, allergies, accidents, illnesses, operations, hospitalizations. Family History includes family members’ health history. Social history to include habits, residence, financial situation, outside assistance, family inter- relationships. Review of Systems relevant to the chief complaint/presenting problem is included. Include pertinent positives and negatives. Objective Using inspection, palpation, percussion, and auscultation, the examiner evaluates all systems associated with the subjective complaint including all systems which may be causing the problem or which will manifest or may potentially manifest complications and records positive and pertinent negative findings Performs appropriate diagnostic studies if equipment is available Records results of pertinent, previously obtained diagnostic studies. Use Handout Guidelines to Physical Examination. Assessment Diagnosis/es is (are) derived from the subjective and objective data Differential diagnoses are prioritized Diagnosis/es come(s) from the medical and/or nursing domain Assessment includes health risks/needs assessment Plan Appropriate diagnostic studies with rationale Therapeutic treatment plan with rationale Was this patient appropriate for a nurse practitioner as a provider? Is consultation or collaboration with another health care provider required? Health promotion/disease prevention carried out or planned: education, discussion, handouts given, evidence of patient’s understanding. What community resources are available in the provision of care for this client? Referrals initiated (including to whom the patient is referred to and the purpose) Target dates for re-evaluating the results of the plan and follow up Other Information is typed, double-spaced, 12pt font, and concise (using short paragraphs and phrases) Information is written so that the objective reader can follow the progression of events and information Only standard, accepted medical terminology and abbreviations are used. A minimum of three (3) references from recent (not greater than 5 years old) professional peer reviewed journal publications are required for each (APA format). These can include but not limited to medical, research, pharmacological or advanced practice nursing journals. A quality paper will have greater than 3 references. Rationales need to include a clear demonstration of the use of evidence-bated practice in decision- making. Risks and benefits as well as how an intervention was determined to be evidence-based will be clear to the reader.