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| ASSIGNMENT CONTENT |
| Category |
Points |
% |
Description |
| Assessment: Primary diagnosis |
24 |
15 |
Presentation of the case study patient’s primary diagnosis includes the following required elements:
Diagnosis is consistent with the cited guideline recommendations or scholarly reference, ICD10 code is listed, rationale statement includes a one to two sentence paraphrased pathophysiology statement. The rationale statement includes pertinent positive and negative subjective and objective findings from the history and physical exam, which links this diagnosis to the case study patient. Pertinent lab results are included and interpreted within the rationale statement. |
| Assessment: Secondary diagnosis (es) |
16 |
10 |
Presentation of the case study patient’s secondary diagnosis (es) include (s)the following required elements:
Diagnosis is consistent with the cited guideline recommendations or scholarly reference, ICD10 code is listed, rationale statement includes a one to two sentence paraphrased pathophysiology statement. The rationale statement includes pertinent positive and negative subjective and objective findings from the history and physical exam, which links this diagnosis to the case study patient. Pertinent lab results are included and interpreted within the rationale statement. |
| Evidence-Based Practice (EBP) |
40 |
25 |
National guidelines are used to support all diagnoses and develop the management plan.
The American Diabetes Association Standards and Medical Care in Diabetes-2019 or later, (or article related to 2019 or later Guidelines) are used to support the primary diagnosis and develop the management plan.
Every diagnosis rationale must include an in-text citation to a scholarly reference as listed in the Reference Guidelines document. Each action step or order within all plan sections includes an in-text citation to an appropriate reference as listed in the Reference Guidelines document. Reference interpretation is accurate. |
| Plan: Diagnostics |
8 |
5 |
All ordered diagnostics tests are linked to a diagnosis listed in the assessment section and include a paraphrased EBP rationale with citation and include date when test should be performed (ie: today, 1 week, 1 month). Further testing/diagnostics for the differential diagnosis is included. Plans are consistent with the cited guideline recommendations or scholarly reference. |
| Plan: Medications |
8 |
5 |
The plan includes both prescribed and OTC medications written in prescription format. The plan includes a minimum of one OTC medication. Each prescribed and OTC medication is linked to a diagnosis listed in the assessment section
Diagnosis is clearly stated in the rationale statement. And includes a paraphrased rationale EBP rationale |
| Plan: Education |
8 |
5 |
All education steps are linked to a diagnosis, paraphrased, and include an EBP rationale.
This section is written exactly how you would discuss the education to the patient. Use vocabulary which the patient can understand, not medical terminology.
Section includes personalized detailed education on diagnoses, medications, diet, exercise and any warning signs. Personalized diet and exercise recommendations are appropriate for the case study patient and include specific instructions for the case study patient such as a specific exercise- length of time to exercise and frequency/week. Any published diet recommendations, such as a Mediterranean diet, will include a rationale statement as to why this recommendation is beneficial for the case study patient.
Plans are consistent with the guideline recommendations or scholarly reference. |
| Plan: Referrals |
8 |
5 |
All recommended referrals are appropriate for the patient diagnoses:
each referral is linked to a specific diagnosis each which was listed in the assessment section and includes a paraphrased EBP rationale. All referrals related to the primary diagnosis are obtained from the ADA guidelines.
Plans are consistent with the cited guideline recommendations or scholarly reference |
| Plan: Follow up |
8 |
5 |
Follow up includes a specific time/date to return to PCP office. EBP rationale with in text citation is included. Only follow up information is listed in this section. Additional information, such as future testing, education or referrals are not listed in follow up but within the appropriate paper sections. Plans are EBP and consistent with the guideline recommendations. |
| Assessment of comorbidities |
16 |
10 |
The ADA guidelines includes a Comprehensive Medical Evaluation and Assessment of Comorbidities section which includes comorbidities that providers should consider when managing disorders of glucose metabolism.
Choose one of the listed comorbidities from the ASSESSMENT OF COMORBIDITIES subsection*
Explain the significance of and the relationship between your primary diagnosis and your chosen comorbidity. Explain how one diagnosis affects the other diagnosis in no more than 3-5 sentences. Include any recommended screening, diagnostic testing, and referrals in no more than 2-3 sentences.
* the chosen comorbidity cannot be any secondary diagnosis already discussed in your paper’s assessment section. |
| Medication costs |
8 |
5 |
All monthly medication costs are calculated, including the current medications the patient may be already taking.
A total cost for all the month’s medication is included.
All medications including OTCs are included.
Medication cost reference source is included. Summary/reflection statement regarding medication costs and any medications changes based on cost or polypharmacy concerns is included. |
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Total CONTENT Points= [144 pts] |
| ASSIGNMENT FORMAT |
| Category |
Points |
% |
Description |
| Grammar, Syntax, APA
|
8 |
5 |
APA format, grammar, spelling, and/or punctuation are accurate, or with zero to one error. All referenced information is cited, “according to” is not used. All cited information is paraphrased, no quotes are included in the paper. |
| Organization |
8 |
5 |
Paper is developed in a logical, meaningful, and understandable sequence.
Provided assignment template is used to develop the paper. The rationale length does not exceed template directions. The paper length does not exceed 10 pages, excluding title page and references.
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|
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Total FORMAT Points= [16 pts] |
| |
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ASSIGNMENT TOTAL=160 points |
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Solution:
Case Study
This analysis aims to evaluate the available patient’s subjective and objective data during the visit, and carry out the appropriate diagnosis, create a plan for effective care as per the American Diabetes Association (ADA) guidelines.
Assessment
Primary: Type 2 diabetes mellitus (E11)
Pathophysiology: Type 2 diabetes is considered a metabolic dysfunction, that prevents the body to use the available insulin appropriately. The hallmark of type 2 diabetes involved decrease uptake of glucose, an increase in hepatic glucose production, and impaired insulin secretion (Galicia-Garcia et al., 2020). According to the American Diabetes Association (2020a), the clinical findings in T2DM include blurry vision, feeling of hunger and thirst, frequent urination, bruises that are slow to heal, weight loss, tingling, numbness, or pain on the hand or feet. The patient may also experience excessive fatigue.
Pertinent positive findings: AJS present with classic symptoms such as thirst, frequent urination and thirst, and extreme hunger, which are key symptoms of T2DM (ADA, 2020a). AJS is obese, comes from Pacific Islander, which has a high prevalence of T2DM, the A1C test is 11.9 %, high blood pressure ( 172/100), 58 y-o, in which age is a risk factor of T2DM, Glucose +1, urinary albumin excretion rate 250mg/day, which may be a sign of kidney complication caused by T2DM. AJS has also not been engaging in physical activity for the past 6 months. A family history of T2DM. mother and brother have mother Type II DM.
Pertinent negative findings: AJS has been feeling bloated after every meal and has challenges in concentrating at work. increased hunger is one of the classical symptoms of T2DM but it is not present, instead, AJS feels bloated (ADA, 2020a). These symptoms are not signs and .To access the solution click the icon below to purchase at $10