MN568 Hypertension Case Study This Assignment will assess your ability to evaluate subjective and objective information in order to arrive at an appropriat

MN568 Hypertension Case Study This Assignment will assess your ability to evaluate subjective and objective information in order to arrive at an appropriate diagnosis and treatment plan for the patient.

Hypertension Case Study

C.D is a 55-year-old African American male who presents to his primary care provider with a 2-day history of a headache and chest pressure.

PMH

Allergic Rhinitis

Depression

Hypothyroidism

Family History

Father died at age 49 from AMI: had HTN

Mother has DM and HTN

Brother died at age 20 from complications of CF

Two younger sisters are A&W

Social History

The patient has been married for 25 years and lives with his wife and two children. The patient is an air traffic controller at the local airport. He has smoked a pack of cigarettes a day for the past 15 years. He drinks several beers every evening after work to relax. He does not pay particular attention to sodium, fat, or carbohydrates in the foods he eats. He admits to “salting almost everything he eats, sometimes even before tasting it.” He denies ever having dieted or exercised.

Medications

Zyrtec 10 mg daily

Allergies

Penicillin

ROS

States that his overall health has been fair to good during the past year.

Weight has increased by approximately 30 pounds in the last 12 months.

States he has been having some occasional chest pressure and headaches for the past 2 days. Shortness of breath at rest, headaches, nocturia, nosebleeds, and hemoptysis.

Reports some shortness of breath with activity, especially when climbing stairs and that breathing difficulties are getting worse.

Denies any nausea, vomiting, diarrhea, or blood in stool.

Self treats for occasional right knee pain with OTC Ibuprofen.

Denies any genitourinary symptoms.

Vital Signs

B/P 190/120, HR 73, RR 18, T. 98.8 F., Ht 6’1”, Wt 240 lbs.

HEENT

TMs intact and clear throughout

No nasal drainage

No exudates or erythema in oropharynx

PERRLA

Funduscopy reveals mild arteriolar narrowing without nicking, hemorrhages, exudates, or papilledema

Neck

Supple without masses or bruits

Thyroid normal

No lymphadenopathy

Lungs

Mild basilar crackles bilaterally

No wheezes

Heart

RRR

No murmurs or rubs

Abdomen

Soft and non-distended

No masses, bruits, or organomegaly

Normal bowel sounds

Ext

Moves all extremities well

Neuro

No sensory or motor abnormalities

CN’s II-XII intact

DTR’s = 2+

Muscle tone=5/5 throughout

What you should do:

Develop an evidence-based management plan.
Include any pertinent diagnostics.
Describe the patient education plan.
Include cultural and lifespan considerations.
Provide information on health promotion or health care maintenance needs.
Describe the follow-up and referral for this patient.
Prepare a 3–5-page paper (not including the title page or reference page).

Assignment Requirements:

Before finalizing your work, you should:

be sure to read the Assignment description carefully (as displayed above);
consult the Grading Rubric to make sure you have included everything necessary; and
utilize spelling and grammar check to minimize errors.

Your writing Assignment should:

follow the conventions of Standard English (correct grammar, punctuation, etc.);
be well ordered, logical, and unified, as well as original and insightful;
display superior content, organization, style, and mechanics; and
use APA 6th Edition format as outlined in the APA Progression Ladder. Assignment/Project Rubric
Unit 3 assignment grading rubric.
Instructors: Enter total available points in cell H2, and values between 0 and 4 in the yellow
cells in the Score column.
Total available points =
Content Rubric
Introductory
Emergent
Practiced
Proficient/Mastered
0 – 1.9
2 – 2.9
3 – 3.9
4
Weight
Final Score
The management plan is
The management plan is
The management plan is
partially developed but not mostly developed but the evidence based and completely
based on evidence
evidence base is not strong developed
16%
0,00
There is no evidence of any
diagnostics
Diagnostic tests poorly
addressed
Diagnostics partially
addressed
Diagnostics thoroughly
addressed
15%
0,00
There is no mention of an
education plan
The education plan is
included but it is providercentered vs patientcentered
The education plan is
included and is patientcentered but incomplete
The education plan is included
and is patient-centered and
complete
16%
0,00
15%
0,00
12%
0,00
Develop a patientThere is no mention of a
focused evidence
management plan for this
based management
patient.
plan for this patient.
Pertinent
Diagnostics
Prepare a detailed,
comprehensive,
patient-centered
education plan.
Score
100
Cultural and lifestyle There is no mention cultural
Content poorly addressed
and lifestyle considerations
considerations
Content addressed but more Cultural and lifestyle
detail is needed or content considerations thoroughly
inconclusive
addressed
Information on
health promotion or
Ther is no mention
health care
maintenace needs
Content poorly addressed
Health promotion or health
care main
Describe the
developmental
educational
strategies you will
use with this patient
There is some mention of
developmental educational
strategies but they are not
appropriate for the patient’s
age and developmental
level
The educational strategies
The educational strategies are
are identified and described
well-identified and thoroughly
to great extent but not
described
completely
12%
0,00
There is some description
for the follow up for this
patient but there is not a
specific time line identified
There is a description of the
time line for follow up for
this patient but it is not
supported with evidencebased clinical guidelines
14%
0,00
There is no mention of
development educational
strategies for this education
plan
Describe the followup with specific time
lines for this patient.
There is no mention of
For example, when
follow-up for this patient
should he return to
the clinic for his next
visit?
Health promotion or health care
maintenance needs thoroughly
addressed
There is a description of the time
line for follow up for this patient
and it is well-supported with
evidence-based clinical
guidelines
Content
Score
Writing Deduction
Rubric (everyone
starts with 4’s =
no deductions)
Introductory
Emergent
Practiced
0
Proficient/Mastered
Score
Weight
Final Score
Assignment/Project Rubric
Writing Deduction
Rubric (everyone
starts with 4’s =
no deductions)
Grammar &
Punctuation
Spelling
0-1
The overall meaning of the
paper is difficult to
understand. Sentence
structure, subject verb
agreement errors, missing
prepositions, and missing
punctuation make finding
meaning difficult.
APA
There is some attempt at
APA formatting and citing.
There are one or more
missing parts such as the
cover page or references list.
Citation information may be
missing. Citation mistakes
make authorship unclear.
Weight
Final Score
4
35%
1,40
A few misspelled words normally
Some misspelled words or
caught by spellcheckers are
the misuse of words such as
present but do not significantly
confusing then/than.
interfere with the overall
However, intent is still clear.
readability of the paper.
4
35%
1,40
3
4
Several confusing
sentences or 1 to 2
confusing paragraphs make
understanding parts of the
paper difficult, but the
overall paper meaning is
clear. Many subject verb
agreement errors, run-on
sentences, etc. cause
confusion.
A few confusing sentences
make it difficult to
understand a small portion
of the paper. However, the
overall meaning of a
paragraph and the paper
are intact. There may be a
few subject verb agreement
errors or some missing
punctuation.
There are one or two confusing
sentences, but the overall
sentence and paragraph
meanings are clear. There are a
few minor punctuation errors
such as comma splices or runon sentences.
Many typos, misspelled
The many misspelled words
words, or the use of
and incorrect words choices
incorrect words making
significantly interfere with the
understanding difficult in a
readability.
few places.
Paper has some good
information or research, but it
does not follow assignment
Order of Ideas &
Length Requirement directions and is lacking in
overall organization and
content.
Score
2
The order of information is
confusing in several places
and this organization
interferes with the meaning
or intent of the paper.
However, the paper has a
generally discernible
purpose and follows
assignment directions
overall.
The order of information is
confusing in a few places
and the lack of organization
interferes with the meaning
or intent of the paper in a
minor way.
The overall order of the
information is clear and
contributes to the meaning of
assignment. There is one
paragraph or a sentence or two
that are out of place or other
minor organizational issues. A
few sentences may be long and
hard to understand. Meets length
requirements.
4
20%
0,80
This is an attempt use APA
formatting and citing. There
are both in-text citations and
reference listings. Citation
information may be missing
or incorrect (i.e. Websites
listed as in-text or reference
citations). There is an
attempt to cite all outside
sources in at least one
place. Authorship is
generally clear.
There is an overall attempt
at APA formatting and
citation style. All sources
appear to have some form
of citation both in the text
and on a reference list.
There are some formatting
and citation errors. Citations
generally make authorship
clear.
There is a strong attempt to cite
all sources using APA style.
Minor paper formatting errors
such as a misplaced running
head or margins may occur.
Minor in-text citation errors such
as a missing page number or a
misplaced date may occur.
Quotation marks and citations
make authorship clear.
4
10%
0,40
Writing
Deduction
Final Score
Percentage
Feedback:
0
0
0%
Assignment/Project Rubric

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