Clinical Decision Making CDM #2
N5442 Primary Pediatrics
Maria is a 16 y/o Hispanic female presenting to your clinic today because she received a note from the school nurse reporting that she has Grade 3 acanthosis nigracans. Her Vital signs from school are BP 144/92, HR 88, RR 16, Temp 97.9.
Wt. 195 pounds, Ht: 62 inches, BMI =35.6. You note from her chart that she has not had a check up in 2 years.
Family History: +family history for Diabetes, Type II maternal grandparents
; Hypertension in grandparents
on both sides of the family.
You had Maria do fasting labs before coming to your office today. The results are as follows:
Fasting blood sugar = 118
Total Cholesterol = 190
Triglycerides = 260
LDL = 104
24 hour diet recall:
Breakfast: tortilla with eggs and salsa, glass of whole milk.
Lunch: school lunch – small cheese pizza, bag of potato chips, 1 regular sized snickers bar, and a Capri Sun fruit juice drink.
After school snack: Hot Cheetos, Dr. Pepper
Dinner: spaghetti with meat sauce, 2 slices of French bread with butter, salad with Ranch dressing, Dr.Pepper.
Alert, obviously obese female
HEENT: (unremarkable) Eyes- Clear, Nose clear with no discharge; Tonsils Grade 11 without erythema or exudates; TMs pearly with +cone of light bilaterally.
Heart: S1 and S2 with regular rate, no murmur noted.
Abdomen: Soft, rounded with stria over abdomen; no hepatosplenomegaly
Lymphatic: No palpable nodes
Skin: Darkening pigment over posterior neck measuring 3mm, faint darkening of the skin to the axillary areas and the groin areas bilaterally; multiple stria noted over breasts, upper arms, thighs and hips.
Remember to address each diagnosis and include a practice guideline. Use the practice guideline to guide your diagnosis and treatment plan. May include 2-4 rule out diagnosis and/or differentials. Please note that the patho needs to address each diagnosis as well.
(See sample CDM via e-mail)
The University of Texas at Arlington
School of Nursing
N5442Primary Care Pediatric
TIPS FOR DEVELOPING YOUR CDM:
1. If you have a positive complaint, it must be addressed in the physical exam, assessment, and plan.
2. It is not necessary to do a complete review of systems for an interval visit. You should do an appropriate ROS for the presenting problem, current medications (indicate why patient is taking the medication, i.e., Amoxicillin 250 mg po tid for otitis media, etc.), and status of concurrent health problems only. Pertinent past medical history, family history, and social history should be addressed. Your history should be focused.
3. “Rule out” diagnoses are those diagnoses that are most probable, and must be addressed in the plan (Ex: What do I need to do to rule this out?) A differential diagnosis is merely one that you consider as you are taking the history, and doing the physical exam. It is not addressed in the plan as it is not one of your “most likely”.
4. You may not cite Boynton as your reference for the pathophysiology. You may cite it as rationale for your plan. All sources must be referenced according to APA format. Check web sites (i.e. AAP, CDC, NHLBI, NIH, etc) for the latest guidelines on common diseases in order to practice evidence based primary care.
A Few examples are:
When you are doing your review of systems, the “general” category includes symptoms such as fever, malaise, fatigue, night sweats, and weight change or appetite change. It does not include any objective information such as “alert”, “oriented”, “good historian”.
When you are giving the rationale for medication usage, please explain the drug’s category and action (i.e., third generation cephalosporin antibiotic and is used primarily for gram positive organisms), and why the patient has been prescribed the particular medication. Reference your plan using national guideline.
PLEASE use the following format when preparing your CDM. If a category is not applicable, simply put NA.
N5442 Primary Care Pediatrics
CLINICAL DECISION MAKING GUIDE
I. SUBJECTIVE DATA
A. Chief complaint
B. History of Present Illness
The present illness should include all positive historical findings regardless of where in the history the information normally would be placed. For example, the immunization history should be mentioned here for a patient suspected of having measles, even though immunizations usually are mentioned in the past history. Similarly, a family history of sickle cell anemia should be mentioned in a patient admitted for evaluation of anemia, even though it usually is discussed in the family history.
Begin the present illness with "the patient was in good health until . ..." or, if the patient has a chronic illness, with "the patient was in his usual state of health until . . ." Then begin the story of the present illness with the earliest relevant facts, and proceed in chronological order or use the HPI and seven variables format uses in Advanced Assessment Class.
Remember physical examinations, laboratory evaluations, assessments, and treatments that occurred before this presentation are now part of the history and should be included now, at the appropriate chronological point in the history. Avoid giving your assessment at this point; this belongs later, in the assessment section.
C. Current health data is obtained
1. Current medications
3. Last physical examinations
4. Immunization status
5. LMP and type of birth control (if applicable)
D. Past Medical History
1. Illnesses / trauma
3. OB History
4. Sexual History
5. Emotional/Psychiatric History
E. Family History
F. Personal/Social History
G. Review of Systems (appropriate to clinical scenario)
II. OBJECTIVE DATA
A. Examination of vital signs, appropriate systems, laboratory or diagnostic test (if results are available.)
A. Primary Diagnosis(es) – ICD 9 Codes with pathophysiology that correlates with the patient data for major diagnosis. Include references. This is not to be an “excerpt” from a medical text, rather a rationale for choosing this diagnosis.
B. Differential Diagnosis- ICD-9 Codes with explanation of why you think this is a possible diagnosis based on subjective and/or objective data provided. This is not to be a “laundry” list of ALL diagnosis, only those that fit the data you are given
C. Rule out Nursing Diagnosis (es)- ICD 9 codes if appropriate with explanation of why you think this is an important diagnosis to rule out. Again, this is not a “laundry” list of all possible rule outs, only those that fit the scenario you are given.
D. Nursing Diagnosis (es) x2
A. Write a plan of care for the patient described in the case. Include a detailed, scientific evidence based rationale for each intervention you plan. If you plan a new, controversial, or not widely used intervention, provide specific references and a discussion of the literature supporting the use of the intervention.
B. Diagnostic studies and/or laboratory tests with rationale for each treatment in the management plan and appropriate references. The plan should include how you will “rule-out” or “rule-in” your primary diagnosis and each of the differential diagnosis listed. If you are absolutely sure of the primary diagnosis there will not be a list of differential diagnosis.
C. Medical therapeutics/Nursing therapeutics, prescriptions with rational for each treatment and appropriate references
D. Patient education with references (this includes any teaching for parents or patients)
E. Counseling (when appropriate)
F. Health promotion/health maintenance/Anticipatory Guidance (This is information to keep your patient healthy and safe. This should be information not related to your diagnosis. Any teaching regarding the diagnosis goes under patient education.)
G. Referral (when appropriate)
H. Consults (when appropriate)
I. Follow-up appointments
A. Should reflect pertinent normal and abnormal findings
B. Use appropriate terminology
C. Write-up should be organized and complete
FORMAL CLINICAL DECISION MAKING ASSIGNMENT
EVALUATION GUIDE/GRADE SHEET
Student:___________________________ Date: ____________________
Faculty: ___________________________ Grade: _____________________
20 ______ A. Completed subjective and objective data base as appropriate to scenario. Data prioritized, pertinent positives established.
20 ______ B. Assessments, Differential Diagnosis (es), Rule-outs and Nursing Diagnosis(es) X2 complete and stated appropriately, ICD-9 Code(s).
20 ______ C. Physiological and pathological process leading to diagnosis(es) are documented and referenced.
20 ______ D. Plan is sound, logical, cost-effective and includes both medical and nursing management and referenced. Should put initial tests that are indicated – order these tests first and if additional tests are required, briefly discuss what might be needed at a later time or visit. Include a section entitled Health Promotion/Health Maintenance.
20 ______ E. Rationale and references are provided for each step in management plan. Include a national guideline for your diagnosis
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