This assignment is a PBL that you will complete using the PBL template. There are also questions that you will need to answer briefly after Utilize the PBLE template for this assignment. These can be paragraph or bullet format.
Include ICD 10 codes for each diagnosis.
CC: Abdominal pain that has come in “attacks over the past several months”
HPI: 46 y/o female presents to clinic with persistent c/o epigastric pain. She states that she has been having these symptoms for about the last 4 years and they have steadily gotten worse and unmanageable. The pain is generally located in the epigastric area. Pain when present, can last 3-6 hrs. She is often awaken with this pain at night. She describes the pain as severe, 9/10, mostly dull intense ache, can sometimes have a cramping-like sensation, very intense, steady for hours; occasionally will have burning feeling, this though is not always present with the attacks; sometimes pain radiates to R-side of back by her shoulder. Can experience vomiting at times – pain is really bad when this happens. She may have several attacks/week but then goes weeks without them. No improvement with food, antacids, or defecation, the pain will just slowly go away. Pt currently has mild pain 3/10 in area described no other symptoms being present at this encounter.
Medication: Only OTC antacids when needed and multivitamin. Occasional Acetaminophen. Oxycodone 5mg PO PRN
Herbal: Calcium +D3
PMH: G2P2, spontaneous vaginal deliveries 7 and 10 yrs ago. No other hospitalizations. No chronic illness..
SocHx: Married heterosexual x 15 yrs, monogamous. Currently works as an administrative assistant. Never used tobacco use. History of low back injury that she uses oxycodone for usually 2-3 times a week; positive THC/alcohol use 2-3 times a week. No particular diet, does not exercise; sleeps about 5-6hrs/noc.
ROS
Constitutional: Denies wt loss, fever or chills
ENT: Denies sore throat, alterations in taste; Denies any dental issues
Resp: Denies SOB, cough or difficulty breathing
Card: Denies C/P, racing heart or feeling like her heart is skipping beats; denies leg swelling.
GI: Denies constipation or melena; does experience occasional dyspepsia and bloating. Has found that she has had to stop eating fried food, eggs and butter, symptoms worse when she has these.
GU: Denies any UTI symptoms or seeing any blood in her urine. LMP 2 wks ago occurring Q31 days. Husband had a vasectomy 9 years ago – not using any birth control secondary to this.
Neuro/Mental Hlth: Denies being depressed or anxious normally. When the pain is really bad, this can make her feel anxious as it is so bad.
PE:
VS: Temp 98.6°F, BP 130/84, HR 80, RR 12, Ht 5’ 3”, WT 197lbs
General appearance: no acute distress, hygiene and attire appropriate, engages in the encounter
Resp: All fields cl to auscultation, reap unlabored
Card: RRR, no murmurs or gallops, no pedal edema
GI: BS active x 4quads; abd, flat, soft, mild epigastric discomfort to deep palpation, no rebound tenderness. negative Murphy’s sign at this visit; stool guaiac – negative, normal liver excursion, uncomfortable during liver assessment with deep palpation of the RUQ.
GU: No costovertebral tenderness.
Neuro/Mental Health: A/O x3; PHQ9 – 3; GAD – 1
Additional Questions:
Interpret the guaiac diagnostic data that you were provided. Explain how you used this to come up with your final diagnosis.
Based on your primary diagnosis, what evidence based integrative modalities could be used to make improvements in symptoms/quality of life for this patient?
Rubric
PBLE Rubric sm24
PBLE Rubric sm24
Criteria Ratings Pts
This criterion is linked to a Learning OutcomeCorrect Diff DX and Pertinent Pos/Neg DX information
10 to >8.0 pts
Competent
Correct & appropriate top 3 key differential DX identified along with rational. Leading differential DX correct based on the sub/obj/diag information of the scenario, rationale clearly demonstrates critical reasoning based upon patient scenario. Citation present
8 to >6.0 pts
Competence partially demonstrated
2 of 3 appropriate key differential DX identified. Lead Dif DX is correct, 1 of the remaining two Diff DX is not one of the top three based upon the scenario Correct APA citation present
6 to >4.0 pts
Competence developing (adv beginner)
1 of 3 correct appropriate key differential DX identified. Leading Diff DX may not be correct. 2 of the Diff DX are not ones that would be considered in the top three based upon the scenario.
4 to >0 pts
Competence not meet
Lead differential DX is incorrect and the other diff dx identified not ones that based upon the scenario would be in the three, Review of course learning’s for this subject matter needed. References may not be cited for all pertinent Diff Dx; APA formatting may not correct 1 or less points
10 pts
This criterion is linked to a Learning OutcomePertinent Pos/Neg DX information: (15 points)
15 to >13.0 pts
Competence meet
Each of the correct top 3 differentials based on the scenario presentation have correctly associated critical reasoning elements associated with pertinent positives and negatives to help rule in or out that diagnosis and determine the correct final diagnosis. References correctly cited per APA format
13 to >11.0 pts
Competence partially demonstrated
2 of 3 differential DX pertinent positives (S/S present) and negatives (S/S absent) from case presentation are correctly critically reasoned and linked to each leading differential diagnosis. Minor revisions may be needed. At least 2 of the differentials have correctly demonstrated pertinent positives and negatives to help rule in or out that diagnosis and determine the correct final diagnosis. References may not be cited for all pertinent Diff Dx Pos/Neg; APA formatting may not correct
11 to >7.0 pts
Competence developing (adv beginner)
1/3 Pertinent positives (S/S present) and negatives (S/S absent) from case presentation are correctly critically reasoned to 1/3 diff dx. Leading differential Dx may not be correct. Major revisions may be needed. At least 1 of the differentials have correctly demonstrated pertinent positives and negatives to help rule in or out that diagnosis and determine the correct final diagnosis. References may not be cited for all pertinent Diff Dx Pos/Neg; Citation and APA formatting may not correct/present
7 to >0 pts
Competence not meet
Leading Dif DX is incorrect based on the case scenario, Critical thinking correlation from Subjective/Objective data not properly thought through. Remaining diff DX pos/neg information requires clearer association to the respective diff/DX’s; Key sub/obj elements missed by student in determining top 3 dif DX. Citation and correct APA may be missing/incorrect
15 pts
This criterion is linked to a Learning OutcomePlan of care
15 to >13.0 pts
Competence meet
Succinctly and correctly addresses appropriate care recommendations for the correct primary Diff DX. At least two references present using correct APA format.
13 to >11.0 pts
Competence partially demonstrated
Identified appropriate care recommendations. Minor revisions needed yo better assimilate to. At least one reference present using correct APA format
11 to >7.0 pts
Competence developing (adv beginner)
Mentions care recommendations. Care elements missing, fragmented or not correctly presented Expansion is needed. Inference to reference but not written.
7 to >0 pts
Competence not meet
Student’s plan of care is inadequate with gross deficiencies. (3 or fewer points)
15 pts
This criterion is linked to a Learning OutcomeLearning needs/Additional Questions
5 pts
Competence meet
If assignment required: Learning articulately and concise presented. Needs reflect clear association to clinical reasoning expansion associated with the final diagnosis and plan. If assignment required: Additional questions answered appropriately, application of critical thinking evident and correctly/appropriately demonstrated reflecting understanding as it relates to the scenario
4 pts
Competence partially demonstrated
If the assignment required: Learning is appropriately presented. Clinical reasoning association to final diagnosis is present. Minor revisions for conciseness/clarity needed. If assignment required: Additional questions answered, application of critical thinking with minor elements of continued learning needed as it relates to the questions/scenario
3 pts
Competence developing (adv beginner)
If the assignment required: Learning is reflected upon, clinical reasoning association to the final diagnosis is difficulty to understand from what is written. Additional questions answered, application of critical thinking with major elements of continued learning needed as it relates to the questions/scenario
1 pts
Competence not meet
Learning element and/or question(s) were written on by the student. Clinical reasoning association questions and/or learning need is not understandable revision to improve clarity/conciseness needed.(1 or fewer points)
5 pts
Total Points: 45
