Mr. Smith Case Study Diagnosis

Grading Rubric Criteria:

Making a correct diagnosis

  • An accurate diagnosis is provided
  • Rationale for arrival at the diagnosis with support from literature

Developing a treatment plan

  • A correct and specific pharmacologic and non-pharmacologic treatment plan for the case study patient is provided

Providing the patient or family with resources

  • Three or more patient resources to assist with understanding the treatment plan are provided

Developing a communication plan

  • A communication plan which includes principles of therapeutic communication is included

College-level academic writing with Advanced Practice Professional Souces

  • Professional, peer-reviewed, advanced practice references are used
  • Grammar and mechanics of writing demonstrate graduate level work
  • Adheres to page number requirements

Case Study

Mr. Smith brings his 4-year-old son to your primary care office. He states the boy has been ill for three days. Mr. Smith indicates that he would like antibiotics so he can send his son back to pre-school the next day.

History – Child began with sneezing, mild cough, and low-grade fever of 100 degrees three days ago. All immunizations UTD. Father reports that the child has had only two incidents of URI and no other illnesses.

Social – non-smoking household. Child attends preschool four mornings a week and is insured through his father’s employment. No other siblings in the household.

PE/ROS -T 99, R 20, P 100. Alert, cooperative, in good spirits, well-hydrated. Mildly erythemic throat, no exudate, tonsils +2. Both ears mild pink tympanic membrane with good movement. Lungs clear bilaterally. All other systems WNL.

Do not consider COVID-19 for this patient diagnosis.

For the assignment write a 4-page narrative as the APRN caring for this patient detailing the following:

  1. Diagnose the child and describe how you arrived at the diagnosis (i.e. how you ruled out other diagnoses).
  2. Provide a specific treatment plan for this patient, pharmacologic and nonpharmacologic.
  3. Provide a communication plan for how the family will be involved in the treatment plan.
  4. Provide resources that Mr. Smith could access which would provide information concerning your treatment decisions.
  5. Utilize national standards, your pharm and/or patho book and medical or advanced practice professional sources. Do not use patient-facing sources or general nursing texts to support your diagnosis and treatment.
  6. Use minimum of 3 references to support your concepts. Utilize correct APA formatting and mechanics of professional communication.

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