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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 your current clinical
experience.
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.
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
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. sprained ankle, sore throat, etc.)
you may be omitting certain areas such as GYN, Rectal, Abd,

etc. 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 male and 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:
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 follow-up 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.
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
utilize then choose a non-pharmacologic element of the
therapeutic plan (e.g. this could be hyperbaric therapy, water
therapy, relaxation training, biofeedback, PT, OT, Counseling
[e. g. nutritional, emotional, behavior modification, etc.]or a
Complementary Alternative Medical regimen [e.g. nutritional
therapy, a spiritual intervention, Emotional Freedom Therapy
(EFT), journaling, visual imagery, progressive relaxation,
Cranial Electrical Stimulation (CES), etc.]
Do not copy and paste from credible sources. Paraphrase source

information as you construct your discussion and ensure that
you provide in-text and reference citations for the source.
Clinical Diagnostic Reasoning
:
Include in this section:
1.
Differential diagnoses
Include a list of all of the diagnoses you considered for your list
of ‘differential diagnoses. This list may extend beyond the
diagnoses identified in the ‘A’ section of the paper.
2.
Priority diagnosis discussion
Discuss the key assessment [history and physical exam] findings
that resulted in the identification of the priority
diagnosis/diagnoses indicated in the ‘A’ section of the paper
3.
Rationale for key elements of the plan of care
As an advanced practice student you need to explore the
evidence relative to the patient’s care needs and be able to
document the rationale for the elements of the plan.
Briefly provide rationales for the key elements of the plan of
care [e.g. if a particular HTN medication is prescribed then
reference the current JNC guidelines, if a particular
antimicrobial is prescribed provide the source referenced for the

decision, etc.]
Provide a rationale for any care aspect included in the plan that
is not consistent with the care approaches found in your course
materials, EBP, CPGs or encompassed in the ‘community
standard of care’.
When using credible sources to support your discussion do not
copy and paste from the sources. Paraphrase source information
as you construct your discussion and ensure that you provide in-
text and reference citations for the source.
Ethical and or Cultural Concerns:
Identify any ethical or cultural issues related to this patient’s
care. Include how these concerns were addressed.
Discuss the following:
1.
Review the provisions of the ANA Code of Ethics
Choose at least one of the provisions of the Code and discuss
how your experience with the patient encounter aligns with the
tenants of the provision OR how you advocated for the patient
during the encounter to ensure your actions aligned with the
tenants of the provision.
Link to gain access to the ANA Code of Ethics – you will need
to scroll down to ‘Select One’ [option] to progress to the page
where you will have full access to the Code:
https://www.nursingworld.org/practice-policy/nursing-
excellence/ethics/code-of-ethics-for-nurses/

2.
Discuss actual or potential cultural implications for this
encounter – from the patient’s cultural perspective or your
cultural perspective
Links to articles that explore the issue of cultural concerns in
health care:
https://www.redorbit.com/news/health/1372127/transcultural_nu
rsing_its_importance_in_nursing_practice/
https://journals.lww.com/academicmedicine/Fulltext/2003/0600
0/A_Strategy_to_Reduce_Cross_cultural.6.aspx
https://pdfs.semanticscholar.org/3e50/d2758210e1bd345ccf16 fc
f8dfcd2b1b5ec9.pdf
Barriers to Care:
Construct a discussion that summarizes the barriers/potential
barriers your patient faces relative to their ability to seek or
receive healthcare services and exploration of at least 3 of the
applicable ‘social determinants of health’ for your patient.
Discuss the Following:
1.
The actual and potential barriers you identified for your patient
Your discussion needs to include observations about access to
care, financial barriers, and non-financial barriers beyond
access. Be sure to provide in-text citations as appropriate for

APA style guidelines in your discussion to support the literature
that you reviewed in identifying the actual/potential barriers.
Links to article exploring barriers
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3393009/
https://academic.oup.com/fampra/article/23/3/325/475515
https://www.careatc.com/ehs/3-common-barriers-to-quality-
medical-care
2.
Three priority social determinants of health for your patient
Your discussion needs to include exploration of the three social
determinants of health that you identified as having the most
significant impact on your patient’s health care and health
status. Be sure to provide in-text citations as appropriate for
APA style guidelines in your discussion to support the literature
that you reviewed in identifying the social determinants of
health.
Link to CDC’s information on Social Determinants of Health
https://www.cdc.gov/socialdeterminants/
3.
Health care policy or advocacy initiatives relevant to your
patient’s care
Include in your discussion at least one health care policy or
initiative that you identified in the literature as having the
potential to positively impact the identified actual/potential

barriers or priority social determinants of health for your
patient.
Resources for your ‘search’ include the Herzing Library,
Google Scholar, PubMed, and/or the Virginia Henderson
Repository
https://www.nursingrepository.org/
*Evidence based practice
:
Evidence-Based Practice (EBP) is a thoughtful integration of
the best available evidence, coupled with clinical expertise. As
such it enables health practitioners to address healthcare
questions with an evaluative and qualitative approach. EBP
allows the practitioner to assess current and past research,
clinical guidelines, and other information resources in order to
identify relevant literature while differentiating between high-
quality and low-quality findings. Evidence-Based Practice
includes the application of evidence and the evaluati on of the
outcomes to guide future practice.
This section is a 1-2 paragraph summary of
all
the scholarly evidence utilized to complete this assignment.
New resources, topics or ideas should not be introduced
.
Discuss the following:
1.
Formulate a well-built question.
What clinical questions and terms did you use to direct your
search in the library database?

2.
Identify articles and other evidence-based resources that answer
the question
. Identify all sources (APA citations) used that informed your
decision making in this particular case.
3.
Critically appraise the evidence [research study, evidence based
or clinical practice guidelines, published care standards, etc.] to
assess its validity
. Comment on the quality of the research or evidence based
practice guidelines used. What is the level of evidence? How
credible is it? Is it a just a recommendation or an expected
standard of care?
4.
Apply the evidence and evaluate for areas of improvement.
How valuable was the evidence in understanding and directing
the care in this case? How did it influence your decision
making? Were you able to assess the outcome? If so, are
changes needed?
*
Self-Reflection:
Reflection on decision making
:
This is an area where you look over the data gathered and after
a careful review of the available resources (i.e. text books,
reference readings) will provide a reflection of what might have
been added or deleted that would have made this note more
conclusive or complete. This is not an area to critique the
preceptor. Discuss areas could you have changed? What areas
might you have added, perhaps additional questions you should
have asked in the ROS, or additional areas you may have

assessed for in the PE?
Advanced Practice Practitioner Role Analysis:
Identify the specific person that drove this plan of care and
developed the management, while including detail in how you
advocated for the patient. It is entirely possible, and desirable,
that you drove the development of the plan of care. Include
how an individualized approach was applied to this patient’s
care. Also include how you identified your advocacy for the
role of the Nurse Practitioner.
*Reference Page:
Follow APA guidelines for constructing all reference page
citations and ensure you used APA style for all in-text citations.

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