Amenorrhea Diagnostic and Clinical Reasoning The purpose of this assignment is to provide you the opportunity to expand the scope of your clinical document

Amenorrhea Diagnostic and Clinical Reasoning The purpose of this assignment is to provide you the opportunity to expand the scope of your clinical documentation and your thought processes relative to complex patient care cases.

Select a complex patient Amenorrhea encounter that involves women health issues.
The patient encounter you select should be one of the more complex patient cases that you have experienced with your current clinical patient population. Given that you are to select complex cases, this assignment may not be completed for a ‘general health, well child, well woman, routine OB, routine physical exam (etc.)’ type of encounter. Please See attached for additional information. All requirements must be addressed.Must be in APA format
Based on the attached work create a better improved paper that follows the rubric

I got this paper back and I need help with revision. TEACHERS FEEDBACK

Please look over comments and perhaps consult other examples of diagnostic reasoning papers that will help you write a more succinct, clear paper.

Please make the paper flow logically so that the reader can clearly see the progression. Consult other papers if you have access to examples.

Just make your working and final diagnoses clear and indicate what made you choose the tests that you chose and the treatments you chose.

There are several distracting grammar errors throughout this paper.

Usually this evaluation would include an ROS that addresses whether there is any vaginal discharge, itching or pain present.

The objective documentation of the vaginal GU exam is incomplete – there is no notation of the presence and position of the cervix and uterus. In addition there is not documentation of the bi-manual exam of the ovaries and whether they were able to be palpated or not. There is also no documentation of any discharge, irritation or the more detailed appearance of the vaginal and cervix. Typically there is documentation of whether or not there is cervical motion tenderness as well.

This section should include a list of all of your working diagnoses that are addressed through your diagnostic workup. You should have at least four differential diagnosis and then your final diagnosis. This seems to be out of sequence in the paper with the table. However the table addition showing your working diagnoses was a fortunate addition to your paper.

In reviewing your plan I do not see the diagnosis for which you are treating this patient. In fact I am not sure where your plan begins. It appears that it is under the heading “therapeutic.” What diagnosis are you treating with the estradiol? “Progesterone will also be given to treat some problems with the uterus.” What does this mean? What do you mean by “some problems.” This should be concisely articulated instead of your statement so that the reader knows exactly what you are referring to.

Your differentials and treated diagnosis should be listed out clearly and designated clearly with each one identified with the corresponding workup and reasoning. It appears that this is out of sequence in your paper and appears under the heading “priority diagnosis discussion.”

My suggestion is to keep your sections of your paper in the order of the rubric.

The clinical decision making heading should list why the treatments chosen for the diagnosis were chosen and how you came to these conclusions. Unfortunately your paper under this heading goes straight into pathophysiology – but is not flowing and explaining the basis for clinical decision making. Parts of the plan appear to be in this section with the pharmacology entries.

Your paper reflects evidence based practice with plenty of documentation on the treatments for the differential diagnosis – however I can’t tell the exact diagnosis you are treating as it is not clearly articulated with the accompanying clear articulation of the corresponding treatment.

My suggest is that you format your papers with more clarity for your final diagnosis and then list our the rest of your differentials. When designating your final diagnosis I suggest you indicate it clearly along with the corresponding plan. 1
Diagnostic and Clinical Reasoning Paper Assignment 80 Point Rubric
Criterion
Highly Proficient
Points 15
Subjective Data
Proficient
13
All elements of
subjective data
(CC, HPI, PMH,
Allergy
identification,
Medication
Reconciliation,
Social History,
Family History,
Health Promotion,
and ROS) are
adeptly
documented and
demonstrate
consistent
information across
all aspects
represented
All elements of
subjective data
(CC, HPI, PMH,
Allergy
identification,
Medication
Reconciliation,
Social History,
Family History,
Health Promotion,
and ROS) are
appropriately
documented and
demonstrate
consistent
information across
all aspects
represented
Points 15
Objective Data
All elements of
objective data are
adeptly
documented and
demonstrate
consistency
relative to the
13
All elements of
objective data are
appropriately
documented and
demonstrate
consistency
relative to the
Marginally
Proficient
11
Approaching
Proficiency
9
Not Proficient
Not evident
7
0
All elements of
subjective data
(CC, HPI, PMH,
Allergy
identification,
Medication
Reconciliation,
Social History,
Family History,
Health Promotion,
and ROS) are
satisfactorily
documented but
do not
demonstrate
consistent
information across
all aspects
represented
11
All elements of
objective data are
satisfactorily
documented but
do not
demonstrate
consistency
All elements of
subjective data
(CC, HPI, PMH,
Allergy
identification,
Medication
Reconciliation,
Social History,
Family History,
Health Promotion,
and ROS) are
either not
satisfactorily
documented or do
not demonstrate
consistent
information across
all aspects
represented
9
All elements of
objective data are
either not
satisfactorily
documented or do
not demonstrate
consistency
All elements of
subjective data
(CC, HPI, PMH,
Allergy
identification,
Medication
Reconciliation,
Social History,
Family History,
Health Promotion,
and ROS) are not
satisfactorily
documented and
do not
demonstrate
consistent
information across
all aspects
represented
7
All elements of
objective data are
not satisfactorily
documented and
do not
demonstrate
consistency
No elements of
subjective data
(CC, HPI, PMH,
Allergy
identification,
Medication
Reconciliation,
Social History,
Family History,
Health
Promotion, and
ROS) are
provided in the
assignment
0
No elements of
objective data
are provided in
the assignment
Total
Points
2
Assessment
Plan
information
documented in the
CC, HPI, PMH, and
ROS
information
documented in the
CC, HPI, PMH, and
ROS
Points 10
Assessment
designations and
other elements in
this section are
adeptly
documented and
demonstrate
congruence with
information
documented in the
CC, HPI, PMH, ROS,
and the objective
data
9
Assessment
designations and
other elements in
this section are
appropriately
documented and
demonstrate
congruence with
information
documented in the
CC, HPI, PMH, ROS,
and the objective
data
Points 10
Elements of the
plan are adeptly
documented,
demonstrate
application of
current clinical
practices for the
identified
assessment
designations, and
demonstrate
congruence of
information across
all aspects
represented
9
Elements of the
plan are
appropriately
documented,
demonstrate
application of
current clinical
practices for the
identified
assessment
designations, and
demonstrate
congruence of
information across
all aspects
represented
relative to the
information
documented in the
CC, HPI, PMH, and
ROS
8
Assessment
designations and
other elements in
this section are
satisfactorily
documented but
do not
demonstrate
congruence with
information
documented in the
CC, HPI, PMH, ROS,
and the objective
data
8
Elements of the
plan are
satisfactorily
documented but
either do not
demonstrate
application of
current clinical
practices for the
identified
assessment
designations, or do
not demonstrate
congruence of
information across
relative to the
information
documented in the
CC, HPI, PMH, and
ROS
7
Assessment
designations and
other elements in
this section are
either not
satisfactorily
documented or do
not demonstrate
congruence of
information
documented in the
CC, HPI, PMH, ROS,
and the objective
data
7
Elements of the
plan are either not
satisfactorily
documented, or do
not demonstrate
application of
current clinical
practices for the
identified
assessment
designations, or do
not demonstrate
congruence of
information across
all aspects
represented
relative to the
information
documented in the
CC, HPI, PMH, and
ROS
6
Assessment
designations and
other elements in
this section are not
satisfactorily
documented and
do not
demonstrate
congruence of
information
documented in the
CC, HPI, PMH, ROS,
and the objective
data
6
Elements of the
plan are not
satisfactorily
documented, do
not demonstrate
application of
current clinical
practices for the
identified
assessment
designations, and
do not
demonstrate
congruence of
information across
0
Assessment
designations
and other
elements in this
section are not
provided in the
assignment
0
Elements of a
plan are not
provided in the
assignment
3
Points 10
Clinical Decision
All elements of
Making
Clinical Decision
Making
(pathophysiology,
pharm/alternate
therapy,
differential
diagnoses,
ethical/cultural
concerns, and
barriers) are
adeptly
documented and
demonstrate
congruence with
information across
all preceding
sections (SOAP) of
the assignment
9
All elements of
Clinical Decision
Making
(pathophysiology,
pharm/alternate
therapy,
differential
diagnoses,
ethical/cultural
concerns, and
barriers) are
appropriately
documented and
demonstrate
congruence with
information across
all preceding
sections (SOAP) of
the assignment
Points 10
Evidence-based
Elements of
Practice (EBP)
EBP(formulation of
evidence support
question,
demonstration of
the results of a
scholarly search for
EBP resources or
CPGs, appraisal of
the evidence
located, analysis of
the applicability of
the EBP or CPG
9
Elements of
EBP(formulation of
evidence support
question,
demonstration of
the results of a
scholarly search
for EBP resources
or CPGs, appraisal
of the evidence
located, analysis of
the applicability of
the EBP or CPG
all aspects
represented
8
All elements of
Clinical Decision
Making
(pathophysiology,
pharm/alternate
therapy,
differential
diagnoses,
ethical/cultural
concerns, and
barriers) are
satisfactorily
documented but
do not
demonstrate
congruence with
information across
all preceding
sections (SOAP) of
the assignment
8
Elements of
EBP(formulation of
evidence support
question,
demonstration of
the results of a
scholarly search
for EBP resources
or CPGs, appraisal
of the evidence
located, analysis of
the applicability of
the EBP or CPG
7
All elements of
Clinical Decision
Making
(pathophysiology,
pharm/alternate
therapy,
differential
diagnoses,
ethical/cultural
concerns, and
barriers) are either
not satisfactorily
documented or do
not demonstrate
congruence with
information across
all preceding
sections (SOAP) of
the assignment
7
Elements of
EBP(formulation of
evidence support
question,
demonstration of
the results of a
scholarly search
for EBP resources
or CPGs, appraisal
of the evidence
located, analysis of
the applicability of
the EBP or CPG
all aspects
represented
6
All elements of
Clinical Decision
Making
(pathophysiology,
pharm/alternate
therapy,
differential
diagnoses,
ethical/cultural
concerns, and
barriers) are not
satisfactorily
documented and
do not
demonstrate
congruence with
information across
all preceding
sections (SOAP) of
the assignment
6
Elements of
EBP(formulation of
evidence support
question,
demonstration of
the results of a
scholarly search
for EBP resources
or CPGs, appraisal
of the evidence
located, analysis of
the applicability of
the EBP or CPG
0
Elements of
clinical decision
making are not
provided in the
assignment
0
No elements of
evidence-based
practice are
provided in the
assignment
4
guidelines to this
encounter, analysis
of patient care
values to EBP or
CPGs presented to
them during your
encounter) are
adeptly discussed
and demonstrate
congruence with
information across
all preceding
sections (SOAP and
Clinical Decision
Making) of the
assignment
Points 5
SelfReflective
Reflection/Critique
discussions of
decision making
and advanced
practice
practitioner role
analysis are
adeptly articulated
and logically flow
from the
discussions in the
preceding sections
(SOAP, Clinical
Decision Making,
and EBP) of the
assignment
Points 5
guidelines to this
encounter, analysis
of patient care
values to EBP or
CPGs presented to
them during your
encounter) are
appropriately
discussed and
demonstrate
congruence with
information across
all preceding
sections (SOAP and
Clinical Decision
Making) of the
assignment
guidelines to this
encounter, analysis
of patient care
values to EBP or
CPGs presented to
them during your
encounter) are
satisfactorily
discussed but do
not demonstrate
congruence with
information across
all preceding
sections (SOAP and
Clinical Decision
Making) of the
assignment
4.5
Reflective
discussions of
decision making
and advanced
practice
practitioner role
analysis are
appropriately
articulated and
logically flow from
the discussions in
the preceding
sections (SOAP,
Clinical Decision
Making, and EBP)
of the assignment
4
Reflective
discussions of
decision making
and advanced
practice
practitioner role
analysis are
satisfactorily
articulated but do
not logically flow
from the
discussions in the
preceding sections
(SOAP, Clinical
Decision Making,
and EBP) of the
assignment
4
4.5
guidelines to this
encounter, analysis
of patient care
values to EBP or
CPGs presented to
them during your
encounter) are
either not
satisfactorily
discussed or do not
demonstrate
congruence with
information across
all preceding
sections (SOAP and
Clinical Decision
Making) of the
assignment
3.5
Reflective
discussions of
decision making
and advanced
practice
practitioner role
analysis are either
not satisfactorily
articulated or do
not logically flow
from the
discussions in the
preceding sections
(SOAP, Clinical
Decision Making,
and EBP) of the
assignment
3.5
guidelines to this
encounter, analysis
of patient care
values to EBP or
CPGs presented to
them during your
encounter) are not
satisfactorily
discussed and do
not demonstrate
congruence with
information across
all preceding
sections (SOAP and
Clinical Decision
Making) of the
assignment
3
Reflective
discussions of
decision making
and advanced
practice
practitioner role
analysis are not
satisfactorily
articulated and do
not logically flow
from the
discussions in the
preceding sections
(SOAP, Clinical
Decision Making,
and EBP) of the
assignment
3
0
No reflective
discussions are
provided in the
assignment
0
5
Professional
Communication
The discussions
and exploration of
thoughts are
adeptly provided
and demonstrate
sound grammatical
construction
without readily
detectable errors
in application of
APA style
guidelines
The discussions
and exploration of
thoughts are
appropriately
provided and
demonstrate
sound grammatical
construction with
only minor
detectable errors
in application of
APA style
guidelines
The discussions
and exploration of
thoughts are
satisfactorily
provided but
either do not
demonstrate
sound grammatical
construction or
include several
readily detectable
errors in
application of APA
style guidelines
The discussions
and exploration of
thoughts are either
not satisfactorily
provided, or do not
demonstrate
sound grammatical
construction, or
include several
readily detectable
errors in
application of APA
style guidelines
The discussions
and exploration of
thoughts are not
satisfactorily
provided, do not
demonstrate
sound grammatical
construction, and
include several
readily detectable
errors in
application of APA
style guidelines
No discussions
or exploration
of thoughts are
provided in the
submission
Total Score:
XX/80
1
Diagnostic and Clinical Reasoning Paper Assignment
The purpose of this assignment is to provide you the opportunity to expand the scope of your
clinical documentation and your thought processes relative to complex patient care cases.
1. Select a patient encounter from dysmenorrhea,PCOS,OVarian Cysts,abnormal
Pap,infertility,amenorrhea)
2. The patient encounter you select should be one of the more complex patient cases that
you have experienced with your current clinical patient population. Given that you are to
select complex cases, this assignment may not be completed for a ‘general health, well
child, well woman, routine OB, routine physical exam (etc.)’ type of encounter.
You will need to identify which patient encounter you are expanding your documentation
for by including the Typhon Case ID # under your name on the title page of your paper.
3. For this assignment you will utilize the same SOAP format that you do for your
‘expanded’ Typhon encounters. Construct this assignment ensuring that you adhere to
the writing guidelines provided in the 6th edition APA manual.
Below is the overview of the required elements for this assignment:
*Title Page (Page 1): Follow APA guidelines for running head on page 1, and include
Medical Diagnosis, Student Name, Typhon Case ID #, and Date.
*Subjective (Start of Page 2): Follow APA guidelines for running head on page 2 and
subsequent pages.
CC: chief complaint – What are they being seen for? This is the reason that the patient sought
care, stated in their own words, or paraphrased.
HPI: history of present illness – use the “OLDCART” approach for collecting data and
documenting findings. [O=onset, L=location, D=duration, C=characteristics,
A=associated/aggravating factors, R=relieving Factors, T=treatment, S=summary]
PMH: past medical history – This should include past illness/diagnosis, conditions, traumas,
hospitalizations, and surgical history. Include dates if possible.
2
Allergies: State the offending medication/food and the reactions.
Medications: Names, dosages, and routes of administration.
Social history: Related to the problem, educational level/literacy, smoking, alcohol, drugs, HIV
risk, sexually active, caffeine, work and other stressors. Cultural and spiritual beliefs that impact
health and illness. Financial resources.
Click on the link below to explore the CDC’s information on the ‘social determinants of health’.
https://www.cdc.gov/socialdeterminants/
Family history: Use terms like maternal, paternal and the diseases and the ages they were
deceased or diagnosed if known.
Health Maintenance/Promotion: Immunizations, exercise, diet, etc. Remember to use the
United States Clinical Preventative Services Task Force (USPSTF) guidelines for age
appropriate indicators. This should reflect what the patient is presently doing regarding the
guidelines.
Click on the link below to access information about current guidelines.
https://www.uspreventiveservicestaskforce.org/
Review of Systems (ROS): this is to make sure you have not missed any important symptoms,
particularly in areas that you have not already thoroughly explored while discussing the history
of present illness. You would also want to include any pertinent negatives or positives that would
help with your differential diagnosis. For acute episodic (focused) visits (i.e. sprained ankle, sore
throat, etc.) you may be omitting certain areas such as GYN, Rectal, GI/Abd, etc. While the list
below is provided for your convenience it is not to be considered all-encompassing and you are
expected to include other systems/categories applicable to your patient’s chief complaint.
General: May include if patient has had a fever, chills, fatigue, malaise, etc.
Skin:
HEENT: head, eyes, ears, nose and throat
Neck:
CV: cardiovascular
Lungs:
GI: gastrointestinal
GU: genito-urinary
PV: peripheral vascular
3
MSK: musculoskeletal
Neuro: neurological
Endo: endocrine
Psych:
*Objective:
Physical Examination (PE): either limited for a focused exam or more extensive for a
complete history and physical assessment. This area should confirm your findings related to the
diagnosis. For acute episodic (focused) visits (i.e.GYN, Rectal, Abd, etc.) you may omit other
assessments. All SOAP notes however should have physical examination of CV and lungs.
While the list below is provided for your convenience it is not to be considered all-encompassing
and you are expected to include other systems/assessments applicable to your patient’s chief
complaint. Ensure that you include appropriate female specific physical assessments when
applicable to the encounter. Your physical exam information should be organized using the
same body system format as the ROS section. Appropriate medical terminology describing the
objective examination is mandatory.
VS: vital signs, height and weight, BMI
Gen: general statement of appearance, if there is any acute distress.
Skin:
HEENT: head, eyes, ears, nose and throat
Neck:
CV: cardiovascular
Lungs:
Abd: abdomen
GU: genito-urinary
PV: peripheral vascular
MSK: musculoskeletal
Neuro: neurological exam
Psych:
4
Diagnostic Tests: This area is for tests that were completed during the patient’s appointment that
ruled the differential diagnosis in or out (e.g. – Rapid Strep Test, CXR, etc.).
*Assessment: (number each diagnosis)
Diagnosis/Diagnoses: Start with the presenting chief complaint diagnosis first. Number each
diagnosis. A statement of current condition of all other chronic illnesses that were addressed
during the visit must be included (i.e. HTN-well managed on medication). Remember the S and
O must support this diagnosis. Pertinent positives and negatives must be found in the write-up.
*Plan: (number each plan specific to each diagnosis)
These are the interventions that relate to the above diagnosis and address the following aspects
(they should be separated out as listed below):
Diagnostics: labs, diagnostics testing – tests that you planned for/ordered during the encounter
that you plan to review/evaluate relative to your work up for the patient’s chief complaint.
Therapeutic: changes in meds, skin care, counseling
Educational: information clients need in order to address their health problems. Include followup care. Anticipatory guidance and counseling.
Consultation/Collaboration: referrals, or consult while in clinic with another provider. If no
referral made was there a possible referral you could make and why? Advance care planning.
*Clinical Decision Making
The next section summarizes your critical thinking, decision-making and diagnostic reasoning
skills that provides you the platform to expand on your identified Typhon patient encounter. It is
a reflection of the thought process you used in caring for the patient. Follow the directions under
each section and label each area as appropriate. All information should be in your own words.
Pathophysiology:
Include information in regard to the pathophysiology related to the main diagnosis or illness
process. This will help to understand how the S and O supported the diagnosis you assigned.
5
Do not copy and paste from credible sources. Paraphrase source information as you construct
your discussion of the pathophysiology and ensure that you provide in-text and reference
citations for the source.
Pharmacology: OR (***Alternate – Therapy information):
Choose one drug that was prescribed at this visit or that is taken chronically by the patient to
review. Please include the name of the drug (generic and brand), class, action, excretion, side
effects and interactions, why this particular drug is being prescribed for this particular patient,
what is this drug intended to treat, (specifically antibiotics, what organisms are we treating?).
What other drug could be chosen instead that would work, if any? Keep in mind the cost and
convenience for the patient.
***NOTE: Since the patient encounter you select for this assignment is supposed to be one of
the most complex encounters you have with this course population, the likelihood exists that you
will have a pharmacologic agent to discuss for this assignment requirement. However, if there
are no pharmacologic agents to…
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