Medical History – Medical Problems

Practicum Case Scenario/ Study The following outlines general instructions for the case scenario. Please remember not to include any HIPPA information. Concerns and questions related to care should be included. Include references to treatment plans using APA format.  Case studies are expected to be a minimum of 500 words, detailed and comprehensive.

Plagiarism receipt requires

Please follow the outline as below when submitting your case study:

Case Scenario/Study

Student Name:

Submission Date:

Case Study: (GERD)

Patient Initials, Age, Gender

Subjective information from the patient (History of Present Illness/Symptoms)

Current Medications

Medical History – Medical Problems

Objective findings from physical examination

Vital Signs, Weight, Height, BMI

Focused examination findings based on diagnoses being addressed.

Assessment

ICD-10 Diagnosis (include ICD-10 code)

Nursing Diagnoses https://nurse.org/resources/nursing-diagnosis-guide/

Plan

Care Plan based on the diagnosis. (Use Nurses lab for care plan)

Include specific nursing care planning for patients to include.

Potential issues with achieving quality, comprehensive care.

Information on best practice care considerations.

Care outcomes from current treatment

Possible side effects of medications or treatments

Patient education planning/instructions

Care outcomes

Plans for the follow-up to review response to treatment.

References:

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