Unit 9 assignment

case study–see attachment

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Rubric Title: MN552 Unit 2 Assignment Rubric

Assignment Criteria	Level III	Level II	Level I	Not Present
Criteria 1	Level III Max Points Points: 30	Level II Max Points Points: 24	Level I Max Points Points: 18	Not Present 0 Points
Part 1 – Provides Video tape of interview of selected patient	· All data, history and biographical data is addressed in video	· More than 50% of data, history and biographical data is addressed in video	· Less than 50% of data, history and biographical data is addressed in video	· Does not meet the criteria
Criteria 2	Level III Max Points Points: 5	Level II Max Points Points: 4	Level I Max Points Points: 3	Not Present 0 Points
Part 2– Provides Data and Source of History and Biographical Data	· All history and biographical data is addressed	· More than 50% of history and biographical data is addressed	· Less than 50% of history and biographical data is addressed	· Does not meet the criteria
Criteria 3	Level III Max Points Points: 5	Level II Max Points Points: 4	Level I Max Points Points: 3	Not Present 0 Points
Part 2 – Provides Data on the patient’s chief complaint and history of present illness	· All data on chief complaint and history of present illness is addressed	· More than 50% of data on chief complaint and history of present illness is addressed	· Less than 50% of data on chief complaint and history of present illness is addressed	· Does not meet the criteria
Criteria 4	Level III Max Points Points: 5	Level II Max Points Points: 4	Level I Max Points Points: 3	Not Present 0 Points
Part 2 – Provides Data on the patient’s past medical and family history	· All data on past medical history and family history is addressed	· More than 50% of data on past medical history and family history is addressed	· Less than 50% of data on past medical history and family history is addressed	· Does not meet the criteria
Criteria 5	Level III Max Points Points: 5	Level II Max Points Points: 4	Level I Max Points Points: 3	Not Present 0 Points
Part 2 – Provides Data on the patient’s lifestyle patterns	· All data on patient’s lifestyle patterns is addressed	· More than 50% of data on patient’s lifestyle patterns is addressed	· Less than 50% of data on patient’s lifestyle patterns is addressed	· Does not meet the criteria
Criteria 6	Level III Max Points Points: 30	Level II Max Points Points: 24	Level I Max Points Points: 18	Not Present 0 Points
Part 2 – Provides Data on the patient’s review of systems (ROS)	· A complete review of systems (ROS) of the patient is addressed	· More than 50% of data on patient’s review of system is addressed	· Less than 50% of data on patient’s review of systems is addressed	· Does not meet the criteria
Criteria 7	Level III Max Points Points: 10	Level II Max Points Points: 8	Level I Max Points Points: 6	Not Present 0 Points
College-level academic writing, Citations and Formatting	· Professional, peer-reviewed, advanced practice references are used · Grammar and mechanics of writing demonstrate graduate level work · There is a strong attempt to cite all sources using APA style. · Minor paper formatting errors may occur. · Minor in-text citation errors may occur. · All authorship is clear and retrievable.	· The majority of references used are professional, peer-reviewed and advanced practice focused · Errors in grammar or mechanics of writing are present but does not interfere with readability · There is an overall attempt at APA formatting and citation style. · Errors in formatting of citation or sources are present. · All sources have some form of citation and all citations have a matching source. · Citations make authorship clear.	· The minority of references are peer-reviewed or advanced practice focused · Errors in grammar or mechanics of writing interfere with readability. · There is some attempt to use citation and referencing. · There are both in-text citations and reference listings present. · Major errors in citations or source formatting are present. · Citation or source information may be missing or incorrect. · Authorship may be unclear.	· Does not meet criteria
Maximum Total Points	90	72	54	0
Minimum Total Points	73 points minimum	55 points minimum	1 point minimum	0

Rubric Title: MN552 Unit 4 Assignment Rubric

Assignment Criteria	Level III	Level II	Level I	Not Present
Criteria 1	Level III Max Points Points: 20	Level II Max Points Points: 16	Level I Max Points Points: 12	Not Present 0 Points
Part 1 – Written document of findings on selected patient	· All written data is addressed	· More than 50% of written data is addressed	· Less than 50% of written data is addressed	· Does not meet the criteria
Criteria 2	Level III Max Points Points: 10	Level II Max Points Points: 8	Level I Max Points Points: 6	Not Present 0 Points
Part 2– Illustrates assessment of patient f	· Includes 100% of the assessment completed for signs of respiratory difficulty and inspection for the shape and movement of the chest.	· Includes more than 50% of assessment completed for signs of respiratory difficulty and inspection for the shape and movement of the chest.	· Includes less than 50% of assessment completed for signs of respiratory difficulty and inspection for the shape and movement of the chest.	· Does not meet the criteria
Criteria 3	Level III Max Points Points: 15	Level II Max Points Points: 12	Level I Max Points Points: 9	Not Present 0 Points
Part 2 – Assess for chest expansion; palpate for tactile fremitus posteriorly; percuss the posterior chest and assess diaphragmatic excursion	· All data is assessed with 100% accuracy for chest expansion, tactile fremitus posteriorly, percussion to the posterior chest and assessment for diaphragmatic excursion.	· Patient is assessed with more than 50% accuracy for chest expansion, tactile fremitus posteriorly, percussion to the posterior chest and assessment for diaphragmatic excursion.	· Patient is assessed with less than 50% accuracy for chest expansion, tactile fremitus posteriorly, percussion to the posterior chest and assessment for diaphragmatic excursion.	· Does not meet the criteria
Criteria 4	Level III Max Points Points: 15	Level II Max Points Points: 12	Level I Max Points Points: 9	Not Present 0 Points
Part 2 – Auscultate posterior breath sounds; auscultate for egophony; bronchophony and pectoriloquy; examine the anterior chest	· Patient is auscultated with 100% accuracy the posterior breath sounds, for egophony, bronchophony and pectoriloquy and examination of the anterior chest	· Patient is auscultated with more than 50% accuracy the posterior breath sounds, for egophony, bronchophony and pectoriloquy and examination of the anterior chest	· Patient is auscultated with less than 50% accuracy the posterior breath sounds, for egophony, bronchophony and pectoriloquy and examination of the anterior chest	· Does not meet the criteria
Criteria 5	Level III Max Points Points: 15	Level II Max Points Points: 12	Level I Max Points Points: 9	Not Present 0 Points
Part 2 – Observe for any abnormalities (size, shape & bruising); palpate for tactile fremitus posteriorly; percuss the anterior chest	· Observation for any abnormalities are accurately performed, palpated for tactile fremitus anteriorly and percussion is performed to the anterior chest with 100% accuracy	· Observation for any abnormalities are performed, palpated for tactile fremitus anteriorly and percussion is performed to the anterior chest with more than 50% accuracy	· Observation for any abnormalities are performed, palpated for tactile fremitus anteriorly and percussion is performed to the anterior chest with less than 50% accuracy	· Does not meet the criteria
Criteria 6	Level III Max Points Points: 15	Level II Max Points Points: 12	Level I Max Points Points: 9	Not Present 0 Points
Part 2 – Auscultate anterior breath sounds; assess JVP, carotid pulses and brachial artery; inspect and locate the PMI	· Auscultation, assessment and inspection is performed with 100% accuracy to anterior breath sounds, JVP, carotid pulses and brachial artery and location the PMI	· Patient is auscultated, assessed and inspected with more than 50% accuracy to anterior breath sounds, JVP, carotid pulses and brachial artery and location the PMI	· Patient is auscultated, assessed and inspected with less than 50% accuracy to anterior breath sounds, JVP, carotid pulses and brachial artery and location the PMI	· Does not meet the criteria
Criteria 7	Level III Max Points Points: 10	Level II Max Points Points: 8	Level I Max Points Points: 6	Not Present 0 Points
Part 2 – Palpate for thrills/bruits; auscultate heart sounds	· Patient is palpated for thrills/bruits and auscultated heart sounds with 100% accuracy	· Patient is palpated with more than 50% accuracy for thrills/bruits and auscultated heart sounds	· Patient is palpated with less than 50% accuracy for thrills/bruits and auscultated heart sounds	· Does not meet the criteria
Maximum Total Points	100	80	60	0
Minimum Total Points	81 points minimum	61 points minimum	1 point minimum	0

Rubric Title: MN552 Unit 6 Assignment Rubric

Unit 6 Assignment Criteria	Level III	Level II	Level I	Not Present
Criteria 1	Level III Max Points Points: 15	Level II Max Points Points: 12	Level I Max Points Points: 9	Not Present 0 Points
Part 1 – Provides written document of findings on selected patient	· All written data is addressed	· More than 50% of written data is addressed	· Less than 50% of written data is addressed	· Does not meet the criteria
Criteria 2	Level III Max Points Points: 15	Level II Max Points Points: 12	Level I Max Points Points: 9	Not Present 0 Points
Part 2 – Inspect the skin and contour of the abdomen; observe for peristalsis and pulsations; auscultate the abdomen	· Patient is inspected, observed and auscultated with 100% accuracy the skin and contour of the abdomen, observation for peristalsis and pulsations and auscultation of the abdomen.	· Patient is inspected with more than 50% accuracy the skin and contour of the abdomen, observation for peristalsis and pulsations and auscultation of the abdomen.	· Patient is inspected with less than 50% accuracy the skin and contour of the abdomen, observation for peristalsis and pulsations and auscultation of the abdomen.	· Does not meet the criteria
Criteria 3	Level III Max Points Points: 15	Level II Max Points Points: 12	Level I Max Points Points: 9	Not Present 0 Points
Part 2 – Auscultate for bruits over the aorta, renal arteries, iliac arteries and femoral arteries; percuss the abdomen; palpate the abdomen (light then deep)	· Auscultation, percussion and palpitations are performed with 100% accuracy for bruits over the aorta, renal arteries, iliac arteries and femoral arteries, percussion of the abdomen and palpation of the abdomen	· Patient is auscultated, percussed and palpated with more than 50% accuracy for bruits over the aorta, renal arteries, iliac arteries and femoral arteries, percussion of the abdomen and palpation of the abdomen	· Patient is auscultated, percussed and palpated with less than 50% accuracy for bruits over the aorta, renal arteries, iliac arteries and femoral arteries, percussion of the abdomen and palpation of the abdomen	· Does not meet the criteria
Criteria 4	Level III Max Points Points: 15	Level II Max Points Points: 12	Level I Max Points Points: 9	Not Present 0 Points
Part 2 – Assess for peritoneal inflammation and rebound tenderness; Murphy’s sign, Rovsing’s sign, Psoas sign, oburator sign; percuss the liver and spleen	· Patient is assessed and percussed with 100% accuracy for peritoneal inflammation and rebound tenderness, Murphy’s sign, Rovsing’s sign, Psoas sign, and Oburator sign and percussion of the liver and spleen.	· Patient is assessed with more than 50% accuracy for peritoneal inflammation and rebound tenderness, Murphy’s sign, Rovsing’s sign, Psoas sign, and Oburator sign and percussion of the liver and spleen.	· Patient is assessed with less than 50% accuracy for peritoneal inflammation and rebound tenderness, Murphy’s sign, Rovsing’s sign, Psoas sign, and Oburator sign and percussion of the liver and spleen.	· Does not meet the criteria
Criteria 5	Level III Max Points Points: 15	Level II Max Points Points: 12	Level I Max Points Points: 9	Not Present 0 Points
Part 2 – Palpate the bilateral kidneys, palpate the width of the Aorta, and assess for CVA tenderness	· Patient is palpated and assessed with 100% accuracy the bilateral kidneys, the width of the Aorta and assessed for CVA tenderness	· Patient is palpated with more than 50% accuracy the bilateral kidneys, the width of the Aorta and assessed for CVA tenderness	· Patient is palpated with less than 50% accuracy the bilateral kidneys, the width of the Aorta and assessed for CVA tenderness	· Does not meet the criteria
Criteria 6	Level III Max Points Points: 15	Level II Max Points Points: 12	Level I Max Points Points: 9	Not Present 0 Points
Part 2 – Assess for cranial nerves 1-12, motor system: muscle bulk, tone strength, coordination, gait and stance	· Patient is assessed with 100% accuracy for cranial nerves 1-12 and for muscle bulk, tone strength, coordination, gait and stance	· Patient is assessed with more than 50% accuracy for cranial nerves 1-12 and for muscle bulk, tone strength, coordination, gait and stance	· Patient is assessed with less than 50% accuracy for cranial nerves 1-12 and for muscle bulk, tone strength, coordination, gait and stance	· Does not meet the criteria
Criteria 7	Level III Max Points Points: 10	Level II Max Points Points: 8	Level I Max Points Points: 6	Not Present 0 Points
Part 2 – Assess for sensory system: pain/temp, vibration, light touch, discrimination; deep tendon reflexes	· Patient is assessed with 100% accuracy for sensory system: pain/temp, vibration, light touch, discrimination and for deep tendon reflexes	· Patient is assessed with more than 50% accuracy for sensory system: pain/temp, vibration, light touch, discrimination and for deep tendon reflexes	· Patient is assessed with less than 50% accuracy for sensory system: pain/temp, vibration, light touch, discrimination and for deep tendon reflexes	· Does not meet the criteria
Maximum Total Points	100	80	60	0
Minimum Total Points	81 points minimum	61 points minimum	1 point minimum	0

Rubric Title: MN552 Unit 8 Assignment Rubric

Unit 8 Assignment Criteria	Level III	Level II	Level I	Not Present
Criteria 1	Level III Max Points Points: 15	Level II Max Points Points: 12	Level I Max Points Points: 9	Not Present 0 Points
Part 1 – Provides written document of findings on selected patient	· All written data is addressed	· More than 50% of written data is addressed	· Less than 50% of written data is addressed	· Does not meet the criteria
Criteria 2	Level III Max Points Points: 15	Level II Max Points Points: 12	Level I Max Points Points: 9	Not Present 0 Points
Part 2 – Performs physical assessment for general survey and states findings allowed	· Patient assessment for physical assessment for general survey and states findings allowed is correct.	· Patient is assessed with more than 50% accuracy for physical assessment for general survey and states findings allowed	· Patient is assessed with less than 50% accuracy for physical assessment for general survey and states findings allowed	· Does not meet the criteria
Criteria 3	Level III Max Points Points: 10	Level II Max Points Points: 8	Level I Max Points Points: 6	Not Present 0 Points
Part 2 – Performs physical assessment for the head, eyes and ears	· Patient is assessed with 100% accuracy for physical assessment for the head, eyes and ears	· Patient is assessed with more than 50% accuracy for physical assessment for the head, eyes and ears	· Patient is assessed with less than 50% accuracy for physical assessment for the head, eyes and ears	· Does not meet the criteria
Criteria 4	Level III Max Points Points: 15	Level II Max Points Points: 12	Level I Max Points Points: 9	Not Present 0 Points
Part 2 – Performs physical assessment for the nose, throat and neck	· Patient is assessed with 100% accuracy for physical assessment for the nose, throat and neck	· Patient is assessed with more than 50% accuracy for physical assessment for the nose, throat and neck	· Patient is assessed with less than 50% accuracy for physical assessment for the nose, throat and neck	· Does not meet the criteria
Criteria 5	Level III Max Points Points: 15	Level II Max Points Points: 12	Level I Max Points Points: 9	Not Present 0 Points
Part 2 – Performs physical assessment for the respiratory and cardiovascular system	· Patient is assessed with 100% accuracy for physical assessment for the respiratory and cardiovascular system	· Patient is assessed with more than 50% accuracy for physical assessment for the respiratory and cardiovascular system	· Patient is assessed with less than 50% accuracy for physical assessment for the respiratory and cardiovascular system	· Does not meet the criteria
Criteria 6	Level III Max Points Points: 15	Level II Max Points Points: 12	Level I Max Points Points: 9	Not Present 0 Points
Part 2 – Performs physical assessment for the GI and GU systems (do not assess their genitals)	· Patient is assessed with 100% accuracy for physical assessment for the GI and GU systems (do not assess their genitals)	· Patient is assessed with more than 50% accuracy for physical assessment for the GI and GU systems (do not assess their genitals)	· Patient is assessed with less than 50% accuracy for physical assessment for the GI and GU systems (do not assess their genitals)	· Does not meet the criteria
Criteria 7	Level III Max Points Points: 15	Level II Max Points Points: 12	Level I Max Points Points: 9	Not Present 0 Points
Part 2 – Performs physical assessment for the musculoskeletal and neurological system	· Patient is assessed with 100% accuracy for physical assessment for the musculoskeletal and neurological system	· Patient is assessed with more than 50% accuracy for physical assessment for the musculoskeletal and neurological system	· Patient is assessed with less than 50% accuracy for physical assessment for the musculoskeletal and neurological system	· Does not meet the criteria
Maximum Total Points	100	80	60	0
Minimum Total Points	81 points minimum	61 points minimum	1 point minimum	0

Rubric Title: MN552 Unit 9 Assignment Rubric

Assignment Criteria	Level III	Level II	Level I	Not Present
Criteria 1	Level III Max Points Points: 20	Level II Max Points Points: 16	Level I Max Points Points: 12	Not Present 0 Points
Part 1 – Identify appropriate differentials	· Identifies more than three differentials for end diagnosis.	· Identifies three differentials for each end diagnosis	· Identifies two differentials for each end diagnosis	· Does not meet the criteria
Criteria 2	Level III Max Points Points: 20	Level II Max Points Points: 16	Level I Max Points Points: 12	Not Present 0 Points
Part 2 – Identify highest priority diagnoses	· Identifies highest risk diagnoses and the correlation between the comorbid diagnoses.	· Identifies highest risk diagnoses but did not correctly correlate the comorbid diagnoses.	· Did not identify high priority diagnosis, but identified correlation between comorbidities	· Does not meet the criteria
Criteria 3	Level III Max Points Points: 15	Level II Max Points Points: 12	Level I Max Points Points: 9	Not Present 0 Points
Part 3 – Identify diagnostic images with rationale.	· Identifies two or more diagnostic images with correct rationale.	· Identifies two diagnostic images with incorrect, or incomplete rationale	· Identifies one diagnostic image with correct rationale	· Does not meet the criteria
Criteria 4	Level III Max Points Points: 15	Level II Max Points Points: 12	Level I Max Points Points: 9	Not Present0 Points
Part 4 – Identify laboratory orders and rationales	· Identifies all laboratory orders with rationales and predicted results.	· Identifies all laboratory orders with some rationales and predicted results.	· Identifies some laboratory orders with rationales and predicted results.	· Does not meet the criteria
Criteria 5	Level III Max Points Points: 20	Level II Max Points Points: 16	Level I Max Points Points: 12	Not Present 0 Points
Part 5 – Discusses patient plan of care	· Comprehensive plan of care is written with rationales discussed	· Comprehensive plan of care is written with incorrect or no rationales discussed	· Plan of care is vague and rationales are lacking.	· Does not meet the criteria
Criteria 6	Level III Max Points Points: 5	Level II Max Points Points: 4	Level I Max Points Points: 3	Not Present 0 Points
College-level academic writing	· Includes no more than three grammatical, spelling, or punctuation errors that do not interfere with the readability · Meets the assignment length requirements · Provides four peer reviewed scholarly sources	· Includes no more than four grammatical, spelling, or punctuation errors that do not interfere with the readability · Meets the length requirements · Provides three peer reviewed scholarly sources	· Includes five or more grammatical, spelling, and punctuation errors makes understanding parts of assignment difficult, but does not interfere with readability · Meets the length requirements · Provides 1-2 peer-reviewed scholarly sources	· Does not meet the criteria
Criteria 7	Level III Max Points Points: 5	Level II Max Points Points: 4	Level I Max Points Points: 3	Not Present 0 Points
Citations and Formatting	· Includes a strong attempt to cite all sources using APA style. · Minor paper formatting errors may occur. · Minor in-text citation errors may occur. · All authorship is clear and retrievable.	· Includes is an overall attempt at APA formatting and citation style. · Errors in formatting of citation or sources are present. · All sources have some form of citation and all citations have a matching source. · Citations generally make authorship clear.	· Includes some attempt to use citation and referencing. · Includes both in-text citations and reference listings present. · Major errors in citations or source formatting are present. · Citation or source information may be missing or incorrect. · Authorship may be unclear.	· Does not meet the criteria
Maximum Total Points	100	80	60	0
Minimum Total Points	81 points minimum	61 points minimum	1 point minimum	0

For this assignment you will be given a case study about a young lady named Sarah Smith. Review the information provided and answer the questions following. Be sure to cite your references. Look at Sarah as if she is a patient in your office seeking care. What are your immediate concerns? What needs to be done for her? Be thorough and succinct in your responses.

Case Study:

Sarah Smith is a 28 y/o African American female who presents to the office with c/o wound to her left foot for the past few days. States she had tripped and fell while barefoot scraping the top of her foot on the pavement. She denies any other injury from the incident. Over the past 24 hours the wound has had “smelly” drainage. Has been experiencing generalized achiness, but denies fever and chills. Did not seek medical attention at the time of injury. Has been using hydrogen peroxide to clean her wound. Is unclear of her last tetanus vaccination. Patient PMHx significant for DM II. States that she takes her medications when she remembers, and does not always check her blood sugar.

PMHx:

Asthma: no hospitalizations for exacerbation.

DM II

PSHx:

Denies

SHx:

Former tobacco user: ceased smoking 2 years ago. Had smoked 1ppd x 5 years

ETOH: socially

Illicit drugs: denies

FHx:

Significant for paternal DM, otherwise unremarkable

Medications:

Metformin: 500mg BID po – did not take the last few days

Albuterol MDI: 2 puffs every 6 hours prn – last use just PTA

Singulair: 10mg po daily

Trinessa: 1 tab po daily – last taken this am

Allergies:

PCN: hives

LNMP: 2 weeks ago.

G0p0

ROS:

General: denies any weight changes, fatigue or fever; + body aches

Skin: denies any rashes; + wound to left foot

HEENT: denies headache, head injury, dizziness, lightheadedness;

Denies any vision changes

Denies any hearing changes, tinnitus, vertigo, earache

Denies any nasal congestion, discharge, nose bleeds or sinus tenderness

Denies any sore throat, difficulty swallowing

Neck: denies any swollen glands, pain

Breasts: denies any pain, discharge

Respiratory: denies any dyspnea; positive cough and wheezing

CV: denies any chest pain, edema

GI: denies any nausea/vomiting/diarrhea/constipation; denies bloody stools

PV: denies claudication, swelling to LE

GU: denies frequency, urgency, burning;

Denies vaginal discharge, itching, sores

Denies penile discharge, itching or sores

MS: positive pain to left foot

Psych: denies nervousness, depression

Neuro: denies Headache, dizziness, vertigo, syncope, weakness; + numbness to right LE

Heme: denies any easy bruising

Physical Exam:

Vital signs: 100.5 (tympanic), 162/88, 118, 22, O2 sat 95% on RA

Height: 5’5” Weight: 250 lbs.

Blood glucose: 230 (Fasting; states has not eaten yet today)

patient awake, alert, oriented x 4 in NAD

Skin: warm, dry, color WNL. 4 cm lesion noted to anterior left foot with crusting and purulent drng; + surrounding erythema extending up 7 cm proximally

HEENT: head nontraumatic, normocephalic

Pupils PERRLA, EOMs intact; disc margins sharp, without hemorrhages, exudates; no AV nicking noted

Ears: bilateral TM with good cone of light and intact

Nose: mucosa pink, septum midline; no sinus tenderness appreciated

Mouth: mucosa pink, moist; tongue midline; tonsils 1+ without exudate

Neck: supple; trachea midline; no LAD

Resp: regular and unlabored; lungs with end expiratory wheezing throughout

CV: RRR, S1 and S2 noted; no s3, s4 or murmur appreciated

Abdomen: soft, non-distended; Bs + x 4; no tenderness with palpation; no CVA tenderness with percussion

Genitalia: deferred

Rectal: deferred

Extremities: warm and without edema; calves supple, non-tender

PV: no LE edema

MS: + swelling to left foot; + tenderness of 2-4th left metatarsals; + left pedal pulse; CMS intact; Cap refill < 2 sec.

Neuro: alert, cooperative; thought coherent; oriented x 4; cranial nerves II-XII intact

Questions:

1. List your differentials for her current problems. Remember you should have at least three different differentials for each problem. Include rationale for each differential.

2. At this time what medical diagnoses are you most concerned about? Do they impact other diagnoses? If so, how?

3. What diagnostic images would you order? Provide your rationale. What are you trying to rule in or out?

4. What laboratory work would you order? What would you anticipate to be abnormal? Provide your rationale for each.

5. What is your comprehensive plan of care? Include your rationales.

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