Case Study

Here are the guidelines & scenario. I have attached a template for reference. Case Study 1 Instructions: 1.Write a case study about the given case scenario using the SOAP format. 2. In your case discussion, answers to the foregoing questions must be established in the primary diagnosis and the pathophysiology related to the diagnosis of this case as follows: What are the three categories of provocative agents that can trigger the medical condition/diagnosis of this patient? What are some possible triggers in this patient? Describe the early events responsible for the pathogenesis of the medical diagnosis of this case. How does this result in chronic airway inflammation and airway hyper -responsiveness. What pathogenetic mechanisms are responsible for this patient's symptoms of wheezing, shortness of breath, and chest tightness. 3. Review and follow the case study writing outline and rubric in building your case and as basis of grading. 4. Paperwork must be submitted via assignment link provided in the Blackboard on or before 6/30/2020 11:59 pm Case Scenario: A 25-year-old previously well woman presents to your office with complaints of episodic shortness of breath and chest tightness. She has had the symptoms on and off for about 2 years but states that they have worsened lately, occurring two or three times a month. She notes that the symptoms are worse during the spring months. She has no exercise-induced or nocturnal symptoms. The family history is notable for a father with asthma. She is single and works as an administrative assistant in a high-tech firm. She lives with a roommate, who moved in approximately 2 months ago. The roommate has a cat. The patient smokes occasionally when out with friends and drinks socially but has no history of illicit drug use. Pertinent PE findings: VS 115/80 HR 84 RR 22 T 98.6 O2 sat 95% room air Pertinent physical examination is notable for mild end-expiratory wheezing. The rest of the PE findings are unremarkable. GUIDELINES FOR INDIVIDUAL 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. 1. Subjective (0.5 point) State the patient’s chief complaint, reason for visit and/or the problem for which the patient sought consultation. a. 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). 2. Associated symptoms 3. Quality of all reported symptoms including the effect on the patient’s lifestyle 4. Temporal factors (date of onset, frequency, duration, sequence of events) 5. Location (localized or generalized? does it radiate?) 6. Sequelae (complications, impact on patient and/or significant other) 7. Severity of the symptoms b. Past Medical History including immunizations, allergies, accidents, illnesses, operations, hospitalizations. c. Family History includes family members’ health history. d. Social history to include habits, residence, financial situation, outside assistance, family inter-relationships. e. Review of Systems relevant to the chief complaint/presenting problem is included. Include pertinent positives and negatives. 2. Objective (0.5 point) a. 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 b. Performs appropriate diagnostic studies if equipment is available c. Records results of pertinent, previously obtained diagnostic studies. d. Use Handout Guidelines to Physical Examination. 3. Assessment (1.5 points) a. Diagnosis/es is (are) derived from the subjective and objective data highlighting the pathophysiology of the case/s. b. Differential diagnoses are prioritized (minimum of 2) c. Diagnosis/es come(s) from the medical and/or nursing domain d. Assessment includes health risks/needs assessment 4. Plan (1.5 points) a. Appropriate diagnostic studies with rationale b. Therapeutic treatment plan with rationale c. Was this patient appropriate for a nurse practitioner as a provider? Is consultation or collaboration with another health care provider required? d. Health promotion/disease prevention carried out or planned: education, discussion, handouts given, evidence of patient’s understanding. e. What community resources are available in the provision of care for this client? f. Referrals initiated (including to whom the patient is referred to and the purpose) g. Target dates for re-evaluating the results of the plan and follow up 5. Other (1 point) a. Information is typed, double-spaced, 12pt font, and concise (using short paragraphs and phrases) b. Information is written so that the objective reader can follow the progression of events and information c. Only standard, accepted medical terminology and abbreviations are used. d. At least three (3) references from recent professional journal publications are required for each (APA format). These can include but not limited to medical, research, pharmacological or advanced practice nursing journals. More than 3 references should be used. e. Rationales need to include a clear demonstration of the use of evidence-based 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. f. Rationales need to include a clear demonstration of the use of evidence-based 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.