Susan Lang is a 24-year-old Caucasian female presenting to the clinic for regular care. She works full-time as an administrative assistant, and relates she loves her job. She has no medical or surgical history, takes no medication, and has no allergies. Family history is non-contributary. Social history is remarkable for cigarette smoking at a rate of ½ packs per day (PPD) since age 14, / EtOH only on weekends, 6-8 hard liquor/ daily, and marijuana smoking. Gyn history is onset of menses age 13, menses every 28-32 days, lasting 4-6 day and using 3 tampons daily. She has some cramping during her menses for which she takes otc Pamprin. She jogs 3-4 times a week, wears seatbelts when in the car, and “occasionally” uses sunscreen. Susan relates she has been having some postcoital bleeding for the past 6 weeks and has had a sore throat for past 3 weeks. She did have a fever for a day or two, but Tylenol took care of it and she thought it was allergies. 

 

Susan’s vital signs are taken and were temperature 97.8, pulse 68, BP 112/64, height 5’6” and weight 118 lbs. (which was the same as last year). BMI 19.04 

 

  • HEENT: WNL except some anterior cervical adenopathy bilaterally, and throat appears reddened. 
  • Lung: clear to auscultation 
  • CV:  regular sinus rhythms without murmur or gallop 
  • Abd:  soft, non-tender, liver normal,  
  • Breasts:  fibrocystic changes bilaterally, no masses, dimpling, redness or discharge, no adenopathy, and bilateral nipple piercings. 
  • VVBSU: wnl, slight frothy yellow discharge by cervix, clitoral piercing noted 
  • Cervix:  friable, some petechia no cervical motion tenderness. 
  • Uterus: mid mobile, non-tender 
  • Adnexa: without masses or tenderness 
  • Perineum: wnl 
  • Rectum: wnl 
  • Extremities:  full rom, skin clear, no edema, reflexes 1+. 
  • Neurological:  CN II-12 grossly intact. 

 

 

 

 

QUESTIONS:

 

  1. What other information do you need? 
  2. What testing would you perform/order? 
  3. What are your initial thoughts for diagnosis? 

 

 

DO NOT POST A SOAP NOTE.Post your primary diagnosis. Include the additional questions you would ask the patient and explain your reasons for asking the additional questions. Then, explain the types of symptoms you would ask. Be specific and provide examples. (Note: When asking questions, consider sociocultural factors that might influence your question decisions.)

Based on the preemptive diagnosis, explain which treatment options and diagnostic tests you might recommend. Use your Learning Resources and/or evidence from the literature to support your recommendations.

 

 

_Discussion_Rubric

 

 

ExcellentPoint range: 90–100GoodPoint range: 80–89FairPoint range: 70–79PoorPoint range: 0–69Main Posting:Response to the case study discussion questions includes appropriate diagnoses with explanations of appropriate diagnostic tests and treatment options as directed, is based on evidence-based research where appropriate, and is incorporates syntheses representative of knowledge gained from the course readings for the module and current credible sources.

Points Range:40 (40.00%) – 44 (44.00%)

Thoroughly responds to the discussion question(s).Post includes approprite diagnoses including explanations of appropriate diagnostic tests and treatment options.Incorporates syntheses representative of knowledge gained from the course readings for the module and current credible sources, with no less than 75% of post the post having exceptional depth and breadth.Supported by at least 3 current credible sources.

Points Range:35 (35.00%) – 39 (39.00%)

Responds to most of the discussion question(s)Post includes approprite diagnoses with explanations of appropriate diagnostic tests and treatment options.Somewhat incorporates syntheses representative of knowledge gained from the course readings for the module and current credible sources with no less than 50% of the post having exceptional depth and breadth.Supported by at least 3 credible references.

Points Range:31 (31.00%) – 34 (34.00%)

Responds to some of the discussion question(s).Post contains incomplete or vague diagnoses or explanations of appropriate diagnostic tests and treatment options.Is somewhat lacking in synthesis of knowledge gained from the course readings for the module and current credible sources.Post is cited with fewer than 2 credible references.

Points Range:0 (0.00%) – 30 (30.00%)

Does not respond to the discussion question(s).Post contains incomplete diagnoses or explanations of appropriate diagnostic tests and treatment options, or diagnoses and/or explanations are missing.Lacks synthesis gained from the course readings for the module and current credible sources.Contains only 1 or no credible references.

Main Posting:Writing

Points Range:6 (6.00%) – 6 (6.00%)

Written clearly and concisely.Contains no grammatical or spelling errors.Further adheres to current APA manual writing rules and style.

Points Range:5 (5.00%) – 5 (5.00%)

Written concisely.May contain one to two grammatical or spelling errors.Adheres to current APA manual writing rules and style.

Points Range:4 (4.00%) – 4 (4.00%)

Written somewhat concisely.May contain more than two spelling or grammatical errors.Contains some APA formatting errors.

Points Range:0 (0.00%) – 3 (3.00%)

Not written clearly or concisely.Contains more than two spelling or grammatical errors.Does not adhere to current APA manual writing rules and style.

Main Posting:Timely and full participation

Points Range:9 (9.00%) – 10 (10.00%)

Meets requirements for timely, full, and active participation.Posts main discussion by due date.

Points Range:8 (8.00%) – 8 (8.00%)

Posts main discussion by due date.Meets requirements for full participation.

Points Range:7 (7.00%) – 7 (7.00%)

Posts main discussion by due date.

Points Range:0 (0.00%) – 6 (6.00%)

Does not meet requirements for full participation.Does not post main discussion by due date.

First Response:Post to colleague’s main post that is reflective and justified with credible sources.

Points Range:9 (9.00%) – 9 (9.00%)

Response exhibits critical thinking and application to practice settings.Responds to questions posed by faculty.The use of scholarly sources to support ideas demonstrates synthesis and understanding of learning objectives.

Points Range:8 (8.00%) – 8 (8.00%)

Response has some depth and may exhibit critical thinking or application to practice setting.

Points Range:7 (7.00%) – 7 (7.00%)

Response is on topic, may have some depth.

Points Range:0 (0.00%) – 6 (6.00%)

Response may not be on topic, lacks depth.

First Response:Writing

Points Range:6 (6.00%) – 6 (6.00%)

Communication is professional and respectful to colleagues.Response to faculty questions are fully answered, if posed.Provides clear, concise opinions and ideas that are supported by two or more credible sources.Response is effectively written in Standard, Edited English.

Points Range:5 (5.00%) – 5 (5.00%)

Communication is mostly professional and respectful to colleagues.Response to faculty questions are mostly answered, if posed.Provides opinions and ideas that are supported by few credible sources.Response is written in Standard, Edited English.

Points Range:4 (4.00%) – 4 (4.00%)

Response posed in the discussion may lack effective professional communication.Response to faculty questions are somewhat answered, if posed.Few or no credible sources are cited.

Points Range:0 (0.00%) – 3 (3.00%)

Responses posted in the discussion lack effective communication.Response to faculty questions are missing.No credible sources are cited.

First Response:Timely and full participation

Points Range:5 (5.00%) – 5 (5.00%)

Meets requirements for timely, full, and active participation.Posts by due date.

Points Range:4 (4.00%) – 4 (4.00%)

Meets requirements for full participation.Posts by due date.

Points Range:3 (3.00%) – 3 (3.00%)

Posts by due date.

Points Range:0 (0.00%) – 2 (2.00%)

Does not meet requirements for full participation.Does not post by due date.

Second Response:Post to colleague’s main post that is reflective and justified with credible sources.

Points Range:9 (9.00%) – 9 (9.00%)

Response exhibits critical thinking and application to practice settings.Responds to questions posed by faculty.The use of scholarly sources to support ideas demonstrates synthesis and understanding of learning objectives.

Points Range:8 (8.00%) – 8 (8.00%)

Response has some depth and may exhibit critical thinking or application to practice setting.

Points Range:7 (7.00%) – 7 (7.00%)

Response is on topic, may have some depth.

Points Range:0 (0.00%) – 6 (6.00%)

Response may not be on topic, lacks depth.

Second Response:Writing

Points Range:6 (6.00%) – 6 (6.00%)

Communication is professional and respectful to colleagues.Response to faculty questions are fully answered, if posed.Provides clear, concise opinions and ideas that are supported by two or more credible sources.Response is effectively written in Standard, Edited English.

Points Range:5 (5.00%) – 5 (5.00%)

Communication is mostly professional and respectful to colleagues.Response to faculty questions are mostly answered, if posed.Provides opinions and ideas that are supported by few credible sources.Response is written in Standard, Edited English.

Points Range:4 (4.00%) – 4 (4.00%)

Response posed in the discussion may lack effective professional communication.Response to faculty questions are somewhat answered, if posed.Few or no credible sources are cited.

Points Range:0 (0.00%) – 3 (3.00%)

Responses posted in the discussion lack effective communication.Response to faculty questions are missing.No credible sources are cited.

Second Response:Timely and full participation

Points Range:5 (5.00%) – 5 (5.00%)

Meets requirements for timely, full, and active participation.Posts by due date.

Points Range:4 (4.00%) – 4 (4.00%)

Meets requirements for full participation.Posts by due date.

Points Range:3 (3.00%) – 3 (3.00%)

Posts by due date.

Points Range:0 (0.00%) – 2 (2.00%)

Does not meet requirements for full participation.Does not post by due date.

Name:NRNP_6552_Week4_Case_Study_Discussion_Rubric

 

 

 

 

 

 

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