Abnormal Labs
History Taking
1. History-Taking-What are your top 5 questions for this patient? (2 pts ea)
o Pertinent to Case Study Scenario
o Questions are focused-leading to your top 3 differentials
o What are some questions you would ask related to the clinical presentation? Why?
o What history data should you collect from this pt in order to narrow your diff? Why?
o Overall quality of history/questions
Physical Examination
2. Physical Examination-Focused Exam (2 pts ea)
o What physical examination findings would CONFIRM or RULE OUT your diagnosis? List 3 with your explanation as to how you confirmed or ruled out your differentials
o What POS/NEG physical Examination data would expect to find/did you find? Pertinent positive & negatives emphasized
o Include ALL systems needed to complete your assessment of your patient
o Would the exam be different for (a) an 80-yr-old male with the same presenting symptoms or (b) for a 3-yr-old female with the same presenting symptoms?
Screening and Diagnostic Testing
o What tests would you order today to confirm or narrow your suspected diff dx, & why?
o #1-should be the probable diagnosis
o What are some probable causes of the presenting symptoms? Include history, physical, environmental, organisms, family history, social history, etc.
Health Maintenance Specific to Patient
5. Health Maintenance Specific to Patient CONCISE, RELEVANT
o Appropriate to age, gender, and risk factors (2.5 pts)
o Health maintenance recommendations/precautions you would consider for this patient? (2.5 pts)
Evidence-Based Plan of Care
6. Evidence-Based Plan of Care
o Specific treatment options are defined including EBP guidelines – identify known and potential barriers (2 pts)
o Accurate first-line pharmacotherapy, drug, dose (3 pts)
o What are some non-pharmacological treatment options that you would recommend if appropriate? (1 pt)
o What is your follow-up plan? Education specific? At what point is a referral indicated? (3 pts)
o On the follow-up visit, what alarming symptoms would prompt you to refer? This should be in your plan when appropriate (1 pt)
o In considering developmental stage and family issues, are there some relevant issues that you would address in your plan of care for this patient? If so, identify them (3 pts)
