Clinical Standard of Practice Presentation
Each student will present a Clinical Practice Presentation . The focus of the presentation must
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reflect current treatment recommendations from accepted professional organizations. See syllabus
Be focus on a power point based in a SOAP clinical/medical note, with a patient assisted in a family practice ofice.
Clinical Standard of Practice Presentation
Students are expected to expand their use of resources for evidence-based
practice beyond the required text and explore nursing and related literature to
improve their understanding and application of advanced interventions. Each
student will present a Clinical Practice Presentation. The focus of the presentation
must reflect current treatment recommendations from accepted professional
organizations. Presentations will be evaluated related to the criteria listed.
Presentations must be no more than eight slides in a PowerPoint format with a
Reference List in APA format, will be no more than 15 minutes in length. Topics
will be listed, and students must sign up for presentation by the second week of
the course. Topics may include pneumonia, COPD, Parkinson’s, pancreatitis,
cholecystitis, Asthma, joint replacement, psoriasis, and others.
Criteria Points
Criteria Points
1 Presents the case including CC, HPI, Hx, ROS and PE findings concisely
2 List possible differential diagnosis with supporting/excluding criteria. 10
3 What labs or tests are typically ordered concerning this condition? What results should the Does NP expect to see with this diagnosis?
4 What medications are typically prescribed for this condition? List specific drugs, starting doses, dose ranges, precautions to keep in mind when prescribing these drugs.
5 What are the outcomes expected or unexpected for this specific condition? Moreover, What patient outcomes will trigger a referral?
6 Provide patient teaching materials specific to their condition
Reference :
You can use MERCK manual
All references not older than 2015
American Psychological Association [APA]. (2010). Publication manual of the
American Psychological Association (6th ed.). Washington, DC:
Dunphy, L. M., Winland-Brown, J., Porter, B., & Thomas, D. (2015). Primary care: Art
and science of advanced practice nursing. 4th ed. FA.Davis. Philadelphia, PA.
ISBN-13: 978-0803638013
Fenstermacher, K., & Hudson, B. T. (2019). Practice guidelines for family nurse
practitioners (5th ed.). Elsevier. St Louis, Ms. ISBN-10: 0323290809
Goroll, A. H., & Mulley, A. G. (2014). Primary care medicine: office evaluation and
management of the adult patient. 7th ed. Wolters Kluwer Health: Philadelphia, PA.
ISBN-13: 978-1451151497
Kennedy-Malone, L., Fletcher, K. R. & Martin-Plank, L. (2014). Advanced Practice
Nursing in the Care of Older Adults. F.A. Davis Company. Philadelphia, PA. ISBN
13: 978-0803624917
Rhoads, J., & Jensen, M. M. (Eds.). (2014). Differential Diagnosis for the Advanced
Practice Nurse. Springer Publishing Company. New York, NY. ISBN-10:
0826110274
Other Resources
1. Agency for Health Care Research and Quality (October 2017). Put prevention into practice. A
step-by-step guide to delivering clinical preventive services: A systems approach. Available at
http://www.ahrq.gov/clinic/ppipix.htm
2. Clinical Evidence, BMJ Publishing Group web site. Available at
http://www.clinicalevidence.org
3. Cochrane Library evidence-based web site. Available at
http://www.cochrane.org/
4. Fronske Web Portal Page. Available at
http://www.myhq.com/public/f/l/flagstaff/
There is a
wealth of access to various sites that can be found here, including evidence-based links and
patient education links.
5. University of California, San Diego: A Practical Guide to Clinical Medicine At
https://meded.ucsd.edu/clinicalmed/
6. Journal of Family Practice POEMs web site. Available at
http://www.essentialevidenceplus.com/
7. U.S. Preventive Services Task Force (USPSTF). Available at
http://www.preventiveservices.ahrq.gov
8. University of Iowa Hospital and Clinics. Virtual Hospital. Available at
https://uihc.org/health
library
9. National Center for Complementary and Alternative Medicine. Available at
http://www.nccam.nih.gov/
10. Nurse Org.
https://nurse.org/resources/nurse-practitioner/#-what-is-a-nurse-practitioner
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PatientInitials: S. M.
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Pt. Encounter Number:1
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Date:01-20-2020
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Age: 78
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Sex: Male
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Allergies:
NKA
Advanced Directives: NO
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SUBJECTIVE
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CC: “STOMACH BURNING AND CHEST DISCOMFORT”
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HPI:
PATIENT IS 78 YEARS OLD HISPANIC MALE, COMPLAINING IF STOMACH BURNING AND RETROSTERNAL DISCOMFORT THAT OCCURS WITHIN 1 HR AFTER EATING AND START 2 MONTH AGO. THE SYMPTOMS ARE RELATED WITH SOME FOODS LIKE COFFE, CHOCOLATTE AND SPICY FOODS. THE CHEST DISCOMFORT IS RELIVED WITH CHEWBABLE TUMS.
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Current Medications: ENALAPRIL 10 MG PO BID HTN, METFORMIN ER 1000MG PO AT NIGHT DM2, ASA 81 MG PO DAILY HEART, PLAVIX 75MG PO DAILY ANTICOAGULANT, ATORVASTATIN 40 MG PO DAILY HLD, METOPROLOL 50 MG PO BID HTN
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PMH: HTN, HLD, DM2 (2006), CAD (2007 ), CORONARY ARTERY BYPASS(2015)
Medication Intolerances: NONE
Allergies: NKA
Chronic Illnesses/Major traumas: DM2, CAD
Screening Hx/Immunizations Hx: CURRENT AND COMPLETE, LAST COLONOSCOPY 2015, LAST EYE EXAMINATION 2019 NORMAL
Hospitalizations/Surgeries: CORONARY ARTERY BYPASS(2015) JACKSON MAIN HOSPITAL
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Family History:
MOTHER DEAD 53YO, MI FATHER DEAD 78YO, ESRD R/T DM2 COMPLICATIONS
MATERNAL GRAND: NO RECALL GRANDMOTHER: DIABETES
PATERNAL GRAND FATHER : NO RECALL GRANDMOTHER :DIABETES
SIBBLING: 3 DAUGHTERS HEALTHY GRANDCHILDRENS: 3 HEALTHY
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Social History: married, former smoker, no alcohol, no illicit drugs, retired, low income with social security supplementary, live with her wife 68 years old in 1-bedroom apt section 8, has Medicaid and Medicare
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ROS
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General: denies fatigue, denies fever, denies headache, lethargy, weakness, night sweats, fainting spells, unconscious, denies weight loss, weight gain, denies dizziness, denies insomnia
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Cardiovascular: report chest discomfort, denies palpitation, denies edema, denies blue fingers/toes, heart murmur. report CAD 2007 and coronary artery bypass 2015
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Skin: denies rash, itching, denies skin lesion, denies change in skin color,
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Respiratory: denies SOB, night sweats, prolonged cough, wheezing, sputum production, denies prior respiratory infections, oxygen at home, denies coughing blood
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Eyes: report cataract right eye, denies eye pain, drainage, discharge, denies vision changes, loss, blurred vision, dryness, denies eye irritation, last eye exam 2019 normal.
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Gastrointestinal: report stomach burning after eating denies nausea late afternoon. denies abdominal pain, blood in stools, denies vomit, bloating, denies diarrhea, constipation.
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Ears: denies earache, discharge, drainage, denies hearing loss or change, denies ringing
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Genitourinary/Gynecological
Denies blood in urine, denies CVA tenderness. Denies incontinence,
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SOAP NOTE
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Nose/Mouth/Throat Denies nasal congestion, change in smelling, denies change in taste sore throat, denies difficult swallow, denies teeth loss, denies oral mucosa lesion
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Musculoskeletal: denies fatigue, denies pain, swelling, stiffness, decreased joint motion, broken bone, serious sprains, arthritis, gout.
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Breast: denies pain, denies masses, lumps, nipple discharge.
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Neurological: denies headache, seizures, loss of consciousness, fainting, weakness, loss of muscle size, muscle spasm, tremors, denies involuntary movements, incoordination, numbness, denies feeling of” pins and needles/tingles “
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Heme/Lymph/Endo denies anemia, easy bruising/bleeding, denies past transfusions, denies increased thirst, denies excessive sweating, denies heat/cold intolerance, denies increased appetite.
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Psychiatric: denies sadness, depression, denies anxiety, change in mood, denies tension, denies hallucinations, denies suicide ideation, memory problems, sleep problems, denies past treatment with psychiatrist, denies change in attitudes towards family and friends
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OBJECTIVE
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Weight 148LBS BMI 24.63
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Temp 97.8
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BP 128/82
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Height 65 INCH
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Pulse 78
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Resp 16
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PHYSICAL EXAMINATION
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General Appearance: Gently 78 year old Hispanic male, alert and oriented to person time and place, well nourished , well groomed, only source of information , able to verbalized her needs , able to communicate without barriers , good behavior, adequate mood, no gait disturbances observed, in no noticeable distress during my interview .
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Skin: intact, no skin lesion, no skin breakdown, no ulcers noted no discoloration, good turgor and normal coloration for her race
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HEENT: normocephalic, PERRLA, EOMs intact. Ear canal patent, no redness no discharge, normal amount of cerumen, tympanic membrane clear, pale gray color. Intact, cone of light present right at 5 o’clock, left at 7 o’clock, no TMJ dysfunction, Neck negative for masses, no goiter, no cervical adenopathy, no jugular vein distention
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Cardiovascular S1 S2 present, no S3 no S4, PMI midclavicular line, no murmur noted at auscultation
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Respiratory: anterior posterior lungs clear at auscultation, no adventitious sounds, expected tactile fremitus, resonant percussion no dullness no tympanic. Eupneic respiration.
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Gastrointestinal Abdomen round, nontender non distended, BS normal active 4 abdominal quadrants, soft, no masses no organomegaly note at palpation.
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Breast: deferred
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Genitourinary: No CVA tenderness, no suprapubic tenderness.
Genitalia: deferred
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Musculoskeletal: No joint deformity, no bone deformity, no muscular atrophy noted, full ROM all synovial joints, full neck ROM spine
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Neurological: Alert and Oriented x 3, sensation intact bilateral upper and lower distal to proximal extremities, speech clear.
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PSYCHIATRIC: NO TICKS, NO BIZZARRE MOVEMENT, NO CRYING, NO DISHEVELED APPAREANCE
ANSWER NEGATIVE TO: -DURING THE PAST MONTH, HAVE YOU FELT DOWN, DEPRESSED OR HOPELESS? AND DURING PAST MONTH, HAVE YOU FELT LITTLE INTEREST OR PLEASURE DOING THINGS?
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Lab Tests: NONE
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Special Tests: NONE
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Diagnosis
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Primary Diagnosis-
· k21.9 – GASTRO-ESOPHAGEAL REFLUX DISEASE WITHOUT ESOPHAGITIS
Differential Diagnoses:
· PEPTID ULCER DISEASE ICD10: K27
· ACHALASIA ICD10: K22.0
· GASTRITIS ICD10: K29.70
PLAN
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Labs:
#1 –
93000 – ELECTROCARDIOGRAM, ROUTINE W/AT LEAST 12 LEADS; W/INTERPRETATION & REPORT
Pharmacology Treatment:
· CONTINUOUS WITH PREVIOUS MEDICATION PROFILE
· OMEPRAZOLE 30 MG po bid FOR 8 WEEKS
Non-Pharmacology Treatment:
· DISCUSSED WITH THE PATIENT IN DETAIL THE BENEFITS, RISK AND SIDE EFFECTS OF PROTON PUMP INHIBITORS MEDICATION IN THE TREATMENT OF GERD
· AVOID ALCOHOL AND SPICY, FATTY OR ACIDIC FOODS THAT TRIGGER HEARTBURN LIKE PEPPERMINT, CHOCOLATE, COFFE.
· EAT SMALLER MEALS, AVOID EAT AFTER CLOSE TO BEDTIME, WEAR LOOSE FITTING CLOTHES
· KEEP UPRIGHT POSITION FOR AT LEAST 30 MIN AFTER ,EALS
Activity
· ENCOURAGE SHORT WALKS AT LEAST 3 TIMES PER WEEKS, EARLY IN THE MORNING OR LATE IN THE AFTERNOON
· KEEP WELL HYDRATED
Referral: NO
Follow Up
· NEXT APPOINTMENT IN 4 WEEKS
· PHONE CALL FOLLOW UP IN 2 WEEKS FOR SUICIDAL SCREENING
· REFERED TO PSYCHOTHERAPY
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References
Buttaro, T. M., Trybulski, J., Polgar, B.P. & Sandberg-Cook, J. (2015). Primary Care: A Collaborative
Practice. Elsevier Health Sciences
Codina, M. L. (2018). Family Nurse Practitioner Certification: Fast Facts and Active Questions. Third
Edition. New York: Springer Publishing Company
Blunt, E. (2009). Family Nurse Practitioner: Nursing Review and Resource manual ( 4th ed., Vol 1).Silver
Spring, MD: American Nurses Credentialing Center.
www.epocrates.com
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