Unit 8 case study

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Sally’s Headaches

Purpose:

The purpose of this assignment is to enhance knowledge of the evaluation and management of acute versus chronic presentation of headache.

Case Study Description:

Sally Jones, 45 years old, presents to the primary care clinic with a complaint of a headache. She says the headache usually comes when she is at work. She works as an administrative assistant for a chief Executive Officer at a local hospital. The headache is usually generalized and bilateral and most of the intensity of pain is around the neck or the back of her head. Sally says, “When the pain comes it is like a tight band around my head.” She says the headaches have been occurring more frequently over the past 30 days. Sally takes “homeopathic” tea she recently bought on her most recent trip to Mexico to visit her family. She does not believe in taking medicine for pain because of the side effects.

Based on the case study please provide a response to each of the following items:

What are the pertinent subjective findings? What other questions would you ask Sally to gain more information about her headaches?

Describe the focused physical assessment you will perform on this patient. Provide rationale for conducting the focused assessment and support with peer-reviewed scholarly references.

Identify the diagnostic studies/tests you will order for this patient (if any). Provide scientific, evidence-based rationale from a nationally accepted clinical guideline to justify the diagnostic studies/tests you will order for this patient.

Develop a list of three differential diagnoses for Sally’s symptoms. Prioritize the three differential diagnoses from the most serious diagnosis to the least significant diagnosis.

What is the most likely diagnosis based on Sally’s history of present illness and chief complaint? Is this condition acute or chronic-provide your justification?

Develop a comprehensive, holistic treatment plan including pharmacologic and non-pharmacologic therapies for this patient taking into consideration Sally’s health belief and cultural belief practices.

Discuss the difference in your pharmacologic intervention in acute versus chronic presentation. How will your treatment change if your patient is an adolescent?

The length of this paper should be 2–3 pages, not including the title page and a reference page.

To view the Grading Rubric for this assignment, please visit the Grading Rubrics section of the Course Resources.

Assignment Requirements:

Before finalizing your work, you should:

· be sure to read the assignment description carefully (as displayed above);

· consult the Grading Rubric (under the Course Resources) to make sure you have included everything necessary; and

· utilize spelling and grammar check to minimize errors.

Your writing assignment should:

· follow the conventions of Standard English (correct grammar, punctuation, etc.);

· be well ordered, logical, and unified, as well as original and insightful;

· display superior content, organization, style, and mechanics;

· include a title and reference page(s); and

· be in APA 7th edition formatting and citation style.

Submit your assignment to the unit Dropbox before midnight on the last day of the unit.

Assignment Rubric

Unit 8 Assignment grading rubric. Instructors: Enter total available points in cell H2, and values between 0 and 4 in the yellow cells in the Score column.
Total available points = 75
Content Rubric Introductory – Not submitted or largely incomplete. Work may indicate very little if any comprehension of content. Emergent – Work shows some comprehension but errors indicating miscomprehension may be present. Practiced – Work indicates overall progress toward comprehension. Minor errors may present. Proficient/Mastered – Work is complete and indicates full comprehension of content. Score Weight Final Score
0 – 1.9 2 – 2.9 3 – 3.9 4
Subjective History None of the pertinent subjective findings are discussed or documented. Some pertinent subjective findings are discussed. Documentation is incomplete Most pertinent subjective findings are identified. Documentation is mostly clear, additional information is needed ALL Perttinent subjective findings are clearly identified and thoroughly documented. 4 10% 0.40
Description of the focused assessment The description of the focused assessment to be performed on this patient is vague. The description of the focused assessment to be performed on this patient is somewhat clear. The description of the focused assessment to be performed on this patient is mostly clear. The description of the focused assessment to be performed on this patient is detailed, thorough, and clear. 4 5% 0.20
Rationale Rationale is not evident and not included for conducting the focused assessment and supported with peer reviewed scholarly references. Rationale is not evident and not included for conducting the focused assessment but there are peer reviewed scholarly references. Rationale is somewhat evident for conducting the focused assessment but there are no peer reviewed scholarly references. Rationale is very evident and included for conducting the focused assessment and there are peer reviewed scholarly references. 4 10% 0.40
Diagnostic studies/tests No Diagnostic studies/tests to be ordered for this patient are identified. Some effort to identify Diagnostic studies/tests to be ordered for this patient. Diagnostic studies/tests to be ordered for this patient are mostly identified. Diagnostic studies/tests to be ordered for this patient are well identified. 4 5% 0.20
Scientific, evidence-based rationale Scientific, evidence-based rationale from a nationally accepted clinical guideline is not included to justify the diagnostic studies/tests ordered for this patient. Scientific, evidence-based rationale from a nationally accepted clinical guideline is included to minimal extent to justify the diagnostic studies/tests ordered for this patient. Scientific, evidence-based rationale from a nationally accepted clinical guideline is included to justify the diagnostic studies/tests ordered for this patient but not an exceptional level. Scientific, evidence-based rationale from a nationally accepted clinical guideline is included to great extent to justify the diagnostic studies/tests ordered for this patient Study. 4 10% 0.40
Differential Diagnosis All of the diagnoses were vague and undeveloped. Clearly developed 1 diagnosis, but diagnoses were vague. Clearly developed 2 diagnoses, 1 diagnosis was vague. Clearly developed 3 differential diagnoses. 4 10% 0.40
Prioritizing Differentials None of the diagnoses were prioritized. Prioritized 1 diagnosis from most serious to least significant. Prioritized 2 diagnoses from most serious to least significant. Prioritized all 3 diagnoses from most serious to least significant. 4 5% 0.20
Rationales for Differentials None of the rationales were clear and thoroughly supported from evidence-based sources. 1 rationale was clear and thoroughly supported from evidence-based sources. 2 rationales were clear and thoroughly supported from evidence-based sources. All 3 rationales were clear and thoroughly supported from evidence-based sources. 4 10% 0.40
Medical Diagnosis Does not accurately identifies the least likely diagnosis based on History of Present Illness (HPI) and chief complaint (CC). Accurately identifies the least likely diagnosis based on History of Present Illness (HPI) and chief complaint (CC). Accurately identifies the almost likely diagnosis based on History of Present Illness (HPI) and chief complaint (CC). Accurately identifies the most likely diagnosis based on History of Present Illness (HPI) and chief complaint (CC). 4 10% 0.40
The differential diagnosis is identified as an acute or chronic illness The differential diagnosis is not identified as an acute or chronic illness. The differential diagnosis is mostly identified to some extent as an acute or chronic illness. The differential diagnosis is mostly identified as an acute or chronic illness. The differential diagnosis is accurately identified as an acute or chronic illness. 4 10% 0.40
Comprehensive, holistic treatment plan A comprehensive, holistic treatment plan including pharmacologic and non-pharmacologic therapies is not mentioned for this patient. A comprehensive, holistic treatment plan (taking into consideration, age, cultural background and heath beliefs) including pharmacologic and non-pharmacologic therapies is included for this patient to some extent. A comprehensive, holistic treatment plan (taking into consideration, age, cultural background and heath beliefs) including pharmacologic and non-pharmacologic therapies is included for this patient is mostly identified. A comprehensive, holistic treatment plan (taking into consideration, age, cultural background and heath beliefs) including pharmacologic and non-pharmacologic therapies is included for this patient and is identified to great extent. 4 10% 0.40
Organization No History, Physical and Screening Tools were submitted. History, Physical and Screening Tools were somewhat organized and overall writing left room for improvement. Some ideas were stated clearly and logically. History, Physical and Screening Tools were well-organized, but overall writing left room for improvement. Most ideas were stated clearly and logically. History, Physical and Screening Tools were thoroughly organized and well-written. All ideas were stated clearly and logically. 4 5% 0.20
(Do Not Change criteria below) Content Score 75
Writing Deduction Rubric (everyone starts with 4’s = no deductions) Introductory Emergent Practiced Proficient/Mastered Score Weight Final Score
0-1 2 3 4
Grammar & Punctuation The overall meaning of the paper is difficult to understand. Sentence structure, subject verb agreement errors, missing prepositions, and missing punctuation make finding meaning difficult. Several confusing sentences, or 1 to 2 confusing paragraphs make understanding parts of the paper difficult, but the overall paper meaning is clear. Many subject verb agreement errors, run-on sentences, etc. cause confusion. A few confusing sentences make it difficult to understand a small portion of the paper. However, the overall meaning of a paragraph and the paper are intact. There may be a few subject verb agreement errors or some missing punctuation. There are one or two confusing sentences, but the overall sentence and paragraph meanings are clear. There are a few minor punctuation errors such as comma splices or run-on sentences. 4 35% 1.40
Spelling The many misspelled words and incorrect words choices significantly interfere with the readability. Many typos, misspelled words, or the use of incorrect words making understanding difficult in a few places. Some misspelled words or the misuse of words such as confusing then/than. However, intent is still clear. A few misspelled words normally caught by spellcheckers are present but do not significantly interfere with the overall readability of the paper. 4 35% 1.40
Order of Ideas & Length Requirement Paper has some good information or research, but it does not follow assignment directions and is lacking in overall organization and content. The order of information is confusing in several places and this organization interferes with the meaning or intent of the paper. However, the paper has a generally discernible purpose and follows assignment directions overall. The order of information is confusing in a few places and the lack of organization interferes with the meaning or intent of the paper in a minor way. The overall order of the information is clear and contributes to the meaning of assignment. There is one paragraph or a sentence or two that are out of place or other minor organizational issues. A few sentences may be long and hard to understand. Meets length requirements. 4 20% 0.80
APA There is some attempt at APA formatting and citing. There are one or more missing parts such as the cover page or references list. Citation information may be missing. Citation mistakes make authorship unclear. This is an attempt use APA formatting and citing. There are both in-text citations and reference listings. Citation information may be missing or incorrect (i.e. Websites listed as in-text or reference citations). There is an attempt to cite all outside sources in at least one place. Authorship is generally clear. There is an overall attempt at APA formatting and citation style. All sources appear to have some form of citation both in the text and on a reference list. There are some formatting and citation errors. Citations generally make authorship clear. There is a strong attempt to cite all sources using APA style. Minor paper formatting errors such as a misplaced running head or margins may occur. Minor in-text citation errors such as a missing page number or a misplaced date may occur. Quotation marks and citations make authorship clear. 4 10% 0.40
Writing Deduction 0
Final Score 75
Percentage 100%
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