Walden University Preventative Health and Assessing PPT

WEEK NINE CASE STUDY  

• Edwardo is a 21-year-old Mexican American male who is about to embark on a rigorous exercise program to lose weight. He works as IT support for an organization, a position that requires most of his shift to be seated in his chair with a headset, responding to IT requests online for the duration of his shift. He is a full-time graduate student in an IT program at the local university. He goes out with friends once weekly “for some fun and relief”, he drinks socially, one to two beers with his friends, does not smoke or use recreational drugs. He takes no medications, has not had a physical since he enrolled in his first college program and that consisted of completing a form. He played football in high school but has had no time for sports since enrolling in his first college program. He considers his studies the most essential aspect for his focus. His parents are healthy and invite him over once weekly for “one good meal” and he takes groceries offered by his mother home so that he has food in his apartment. His parents want to help him stay healthy since he has little time to grocery shop, and often gets a burger on the way home from classes. He sleeps well, feels “sluggish” sometimes, especially during his bus ride to and from work. This concerned him and so he has managed to find time to go to a gym for exercise.  He hopes to feel better and lose at least 30 pounds by working out at the gym. He went to visit a personal trainer for the first session and is surprised to hear his trainer suggest that he go to his primary healthcare provider for a checkup first. He began thinking about his parents and their health habits. Both are working full-time and active and healthy, eat nutritious meals, which he enjoys when he has the time to visit, and they take no meds. He has no brothers or sisters. He is concerned that maybe he will not enjoy the health of his parents and maybe he is doing something wrong since he should have inherited good health from his parents. You learn this during your introductory conversation with him and now you must determine where to begin with this “healthy” young man and apparently, his trainer. You applaud his new plan for exercise and begin to discuss with him some health goals and objectives.

B/P 124/70     H/R 70     R 18   WT  200 pounds   HT  70 inches

• Based on the provided patient information, think about the health history you would need to collect from the patient. 
• Consider what physical exams and diagnostic tests would be appropriate to gather more information about the patient’s condition. Reflect on how the results would be used to make a diagnosis. 
• Identify three to five possible conditions that may be considered in a differential diagnosis or at risk for the patient or that you share with him he is at risk for having. 

Consider clinical guidelines that might support each diagnosis. 

• Develop a realistic preventive health treatment plan for the patient that includes health promotion and patient education strategies for special populations. How would you categorize him as “special population”? Use social determinants of health, information that you gather during your assessment, to guide your realistic preventive health plan.
• Determine if you will refer Edwardo back to his trainer for full approval of an exercise program or will you follow up with him first, or concurrently, or tell him that he should not enter an exercise program now (share your reasoning for your decision). This is primarily a PREVENTIVE health assessment. You will want to provide an evaluation, but no pathology must be found; however, a preventive health plan is a must. Social determinants of health must be considered. Referrals or none? Patient education. How would you plan to work with the trainer who provided this referral?

This is a different kind of case study, however, one you may encounter and one that is really important for you to be able to work through. Enjoy!

PREVENTATIVE HEALTH AND ASSESSING, DIAGNOSING, AND TREATING SPECIAL POPULATIONS

Certain groups of patients have concerns that may be specific to their particular population. Conditions related to men’s or women’s health, older adults, college students, LGBTQ individuals, athletes, those with particular cultural beliefs or concerns, or those undergoing palliative or end-of-life care would all fall under this category. Individuals may identify with more than one category.

For this Assignment, you practice assessing, diagnosing, and treating disorders seen in special population patients.

RESOURCES

Be sure to review the Learning Resources before completing this activity.
Click the weekly resources link to access the resources. 

WEEKLY RESOURCES

To Prepare:

• Review this week’s Learning Resources. Consider preventative health and assessing, diagnosing, and treating special populations.
• Review the case study provided by your Instructor. Based on the provided patient information, think about the health history you would need to collect from the patient. 
• Consider what physical exams and diagnostic tests would be appropriate in order to gather more information about the patient’s condition. Reflect on how the results would be used to make a diagnosis. 
• Identify three to five possible conditions that may be considered in a differential diagnosis for the patient. 
• Consider each patient’s diagnosis. Think about clinical guidelines that might support this diagnosis. 
• Develop a preventative health treatment plan for the patient that includes health promotion and patient education strategies for special populations.

Complete:

Use the Focused SOAP Note Template to address the following:

• Subjective: What details are provided regarding the patient’s personal and medical history?
• Objective: What observations did you make during the physical assessment? Include pertinent positive and negative physical exam findings. Describe whether the patient presented with any morbidities or psychosocial issues.
• Assessment: Explain your differential diagnoses, providing a minimum of three. List them from highest priority to lowest priority and include their CPT and ICD-10 codes for the diagnosis. What would your primary diagnosis be and why?
• Plan: Explain your plan for diagnostics and primary diagnosis. What would your plan be for treatment and management? Include pharmacologic and non-pharmacologic treatments, alternative therapies, and follow-up parameters as well as a rationale for this treatment and management plan.
• Reflection notes: Describe your “aha!” moments from analyzing this case.