fam 2

Jane is a 19 year old college freshman who plays on her school’s soccer team. She presents to college health clinic with complaint of sore throat, fever, fatigue, aches and pains that started abruptly yesterday. She denies cough, runny nose, sinus congestion, nausea/ vomiting, and abdominal pain. A review of her record reveals that her immunizations are up to date. She has a benign PMH / FH. She has no drug allergies. Medications include OCPs.
VS: BP-110/64, T-101.6, HR- 88, R- 16
Physical Exam Findings
HEENT: PERRL, Sclera clear, conjunctiva pink without discharge; ear canals clear bilaterally, no swelling or exudate. TMs pearly grey bilaterally with clearly visible landmarks; nares clear bilaterally with no swelling, erythema or discharge visible; Pharynx erythematous with white tonsillar exudates bilaterally.
Neck: Supple with tender swollen anterior cervical lymph nodes bilaterally.

What additional history items are important?
In addition to the HEENT/neck findings given above, what additional physical exam items are important to perform and record?
Apply the Centor criteria. What did you get and what does that mean?
A diagnosis of GABHS pharyngitis is confirmed. What is your treatment plan?

Please refer to the Grading Rubric for details on how this activity will be graded.

S Question 1
O Question 2
A Question 3
P Question 4

Grading Rubric:
 
ote: Scholarly resources are defined as evidence-based practice, peer-reviewed journals; textbook (do not rely solely on your textbook as a reference); and National Standard Guidelines. Review assignment instructions, as this will provide any additional requirements that are not specifically listed on the rubric.
Clinical Case Study – 100 PointsCriteriaExemplary

Exceeds ExpectationsAdvanced

Meets ExpectationsIntermediate

Needs ImprovementNovice

InadequateTotal PointsSubjective DataIncludes all relevant subjective data necessary for differentiation of the client’s problem. Data is presented in systematic, organized manner consistently.

20 pointsIncludes most subjective data with omission of two minor details or one major detail. Most data is presented in systematic, organized manner.

17 pointsIncludes subjective data but omits four minor details or two major details. Some data is presented in a systematic, organized manner.

15 pointsOmits more than four minor details or more than two major details of the subjective data. Data is not presented in a systematic, organized manner.

Lacking most or all subjective data.

Submits assignment late.

13 points20Objective DataObjective data is complete and consistently presented in an organized manner.

20 pointsObjective data is complete and presented in an organized manner most of the time.

17 pointsObjective data is not complete or is not presented in an organized manner.

15 pointsObjective data is not complete and is not presented in an organized manner.

Lacking most or all objective data.

Submits assignment late.

13 points20AssessmentAssessment, including differential and/or diagnosis (if appropriate), is complete and appropriate to client Diagnostics are complete and appropriate to client.

20 pointsAssessment, including differential and/or diagnosis (if appropriate), is complete but some may not be appropriate for client.

17 pointsAssessment, including differential and/or diagnosis (if appropriate), is not complete but is appropriate.

15 pointsAssessment, including differential and/or diagnosis (if appropriate), is not complete or appropriate, or it is not evident.

Submits assignment late.

13 points20PlanPlan includes all relevant measures 95% to 100% Pharmacologic Non-pharmacologic Education Referral Follow-up.

20 pointsPlan includes all relevant measures 89% to 94% Pharmacologic Non-Pharmacologic Education Referral Follow-up.

17 pointsPlan includes four of the five relevant measures, but the four are complete.

15 pointsPlan is not complete and/or covers only three relevant measures.

Plan and relevant measures are not evident.

Submits assignment late.

13 points20Professional ApplicationCase incorporates four evidence-based practice articles.

10 pointsCase incorporates three evidence-based practice articles.

8 pointsDoes not include an evidence-based practice article but has two or more advanced practice articles.

7 pointsDoes not include evidence-based practice article but has one advanced practice article or does not include evidence-based practice article or advanced practice article.

6 points10Organization, APA, Grammar, and SpellingWell organized content that is clear and concise. Correct APA formatting with no errors.

The writer correctly identifies reading audience, as demonstrated by appropriate language (avoids jargon and simplifies complex concepts appropriately).

There are no spelling, punctuation, or word-usage errors.

10 pointsOrganized content that is informative and supportive of purpose. Correct and consistent APA formatting of references, and cites all references used. No more than one to two unique APA errors.

There are minimal to no grammar, punctuation, or word-usage errors.

8 pointsPoor organization and flow of ideas may distract from the content. Three to four unique APA formatting errors.

The writer occasionally uses awkward sentence construction or overuses/inappropriately uses complex sentence structure. Problems with word usage (evidence of incorrect use of thesaurus) and punctuation persist, often causing some difficulties with grammar. Some words, transitional phrases, and conjunctions are overused.

Multiple grammar, punctuation, or word usage errors.

7 pointsIllogical flow of ideas.

Many APA formatting errors, or no attempt to format in APA.

The writer struggles with limited vocabulary and has difficulty conveying meaning–noting just the broadest of meanings.

Grammar and punctuation are consistently incorrect. Spelling errors are numerous.

Submits assignment late.

6 points10Total Points100