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. 

*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