Assignment: Case Study Maggie Smith- Sore Throat Essay

Assignment Case Study Maggie Smith- Sore Throat Essay

Students will watch the video and fill in the blanks on the documentation.

Complete the SOAP Note. (We have given the history on this note).
Describe 3 of the highest possible differential diagnosis. Rule-in and Rule-out each diagnosis. Example: If a patient presents with a painful knee and your top differentials are osteoarthritis, ACL, and Fracture, you would find Evidence to prove that each of those are possible diagnosis. For osteoarthritis: Rule in: What signs and symptoms match what the patient has. Give the
Assignment Case Study Maggie Smith- Sore Throat Essay

evidence (from peer reviewed based information) to show that the symptoms match. Then rule out: What is lacking to show this is the actual diagnosis? You must prove your thoughts with peer reviewed information. You will do this using the illness script for your 3 differential diagnosis.

SUBJECTIVE:

HPI – 19-year-old established patient accompanied by her roommate for complaint of abdominal pain that is increasing in pain.

Onset –
Location-
Duration –
Character –
Aggravating factors –
Alleviating factors –
Timing –
Severity –

PMH –

Medications –

Assignment Case Study Maggie Smith- Sore Throat Essay

known

PSH-

Social hx:

ROS:

OBJECTIVE DATA

Assessment

Plan: What tests will you order (give rationale). Follow-up? Education?

Illness Scrip	Differentiate #1
Epidemiology
Time Course
Clinical Presentation
Pathophysiology
Lab
Imaging

Illness Scrip	Differentiate #2
Epidemiology
Time Course
Clinical Presentation
Pathophysiology
Lab
Imaging

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Illness Scrip	Differentiate #3
Epidemiology
Time Course
Clinical Presentation
Pathophysiology
Lab
Imaging

Maggie Smith Case #2 & #3

Maggie Smith Case #2 & #3

Criteria

Ratings

Pts

This criterion is linked to a Learning OutcomeSubjective

Includes Appropriate CC, History of Present Illness, Personal and Family History, medications, Allergies, and ROS. Includes VS and Exam description. Written appropriately for a SOAP Note

35.0 pts

26-35 points

Student includes all pertinent Subjective information and does not include Objective information. Terminology and writing is appropriate for SOAP note.

30.0 pts

25-30 points

A portion of the subjective information is not included or a portion of the objective information is included. Terminology and writing is lacking for SOAP note.

25.0 pts

0-25 points

A large portion of the Subjective information is missing or a large amount of Objective information is included. Terminology and writing is poor for SOAP note.

35.0 pts

This criterion is linked to a Learning OutcomeObjective information

Includes VS and Exam description. Written appropriately for a SOAP Note

35.0 pts

26-35 points

Student includes all pertinent Objective information and does not include Subjective information. Terminology and writing is appropriate for SOAP note.

30.0 pts

25-30 points

A portion of the Objective information is not included or a portion of the Subjective information is included. Terminology and writing is lacking for SOAP notes.

25.0 pts

0-25 points

A large portion of the Objective information is not included or a large amount of Subjective information is included. Terminology and writing is poor for SOAP note.

35.0 pts

This criterion is linked to a Learning OutcomeAssessment

The Assessment is written with correct terminology for this case

10.0 pts

8-10 points

The Assessment is written correctly for this case with demonstration of fair understanding of a SOAP note and with correct terminology.

7.0 pts

4-7 points

The Assessment is written correctly for this case with demonstration of good understanding of a SOAP note and with correct terminology.

3.0 pts

0-3 point

The Assessment is written correctly for this case with demonstration of poor understanding of a SOAP note and with incorrect terminology.

10.0 pts

This criterion is linked to a Learning OutcomePlan

The Plan for a comprehensive exam should include any follow-up for this patient. Include any future plans for exams, diagnostics, ect…. that might be appropriate.

10.0 pts

8-10 points

Documentation of an appropriate plan for future diagnostics and or follow-up for this patient. Demonstrates understanding of information to be documented in a plan.

7.0 pts

4-7 points

Documentation of a plan for future diagnostics and or follow-up for this patient. Demonstrates some understanding of information to be documented in a plan.

3.0 pts

0-3 point

Documentation of a poor plan for future diagnostics and or follow-up for this patient. Demonstrates poor understanding of information to be documented in a plan.

10.0 pts

This criterion is linked to a Learning OutcomeIllness Script

Complete the illness script for 3 priority differentials. Answers should be short, including only pertinent information.

5.0 pts

4-5 points

Script is completed with pertinent information for 3 differential diagnosis.

3.0 pts

2-3

Script is completed with fair information for 3 differential diagnosis

1.0 pts

0-1 points

The script is poorly written with minimal effort.

5.0 pts

This criterion is linked to a Learning OutcomeScholarly Writing

Writing is written at the graduate level with no spelling errors. Citations and the reference page are written correctly.

5.0 pts

4-5 points

The assignment demonstrates excellent understanding of graduate level work with appropriate language and terminology and no spelling errors. Citations and reference page are written correctly according to APA format.

3.0 pts

2-3 points

The assignment demonstrates fair understanding of scholarly writing with good grammar and appropriate medical terminology. Few spelling errors <3.

1.0 pts

0-1 points

The assignment demonstrates poor understanding of scholarly writing with poor grammar and inappropriate medical terminology. More than 3 spelling errors.

5.0 pts

Total Points: 100.0