management plan

 

Below is the template you are to follow when developing your management plan. Also, always be sure to complete the EMR on the case. Use this template with each case. It is not a SOAP format as that is not required. Points will be deducted for not utilizing the template.

THIS SECTION IS 30 POINTS!!! Follow the bullet points below. Copy and answer each bullet point on a word document and cut and paste your responses to the management section!

• Primary      Diagnosis and ICD-10 code: Also include any      procedural codes.
• 3-5 Differential Diagnoses- Why? What made you select each one as a DDX? How      did you rule out? This would be a good area to include references.
• Additional laboratory and diagnostic tests: It may be necessary to establish or evaluate a      condition. Some tests, such as MRI, may require prior authorization from      the patient insurance carrier.
• Consults: referrals      to specialists, therapists (physical, occupational), counselors, or other      professionals. If you are sending it to the hospital, what orders would      you write for a direct admit?
• Therapeutic modalities: pharmacological      and nonpharmacological management.
• Health Promotion: Address risk factors as appropriate. Consider      age-appropriate preventive health screening.
• Patient education: Explanations and advice given to patient and      family members.
• Disposition/follow-up instructions: when the patient is to return sooner, and      when to go to another facility such as the emergency department, urgent      care center, specialist, or therapist.
• References (minimum      of 3, timely, that prove this plan follows the current standard of care).

Case study

A 2-year-old female presented to the clinic setting today accompanied by her mother who states

the patient is experiencing cough, runny nose, and fever. She is an otherwise healthy toddler who

is appropriately reaching milestones.

Subjective:

Chief complaint:

Cough, runny nose, and fever

History of present illness:

Emma is a 2-year-old, African American female presenting to the clinic today with her

mother who is complaining of the patient having symptoms of cough and runny nose for two

days and fever of 101 since yesterday. Emma’s mother denies sputum when she coughs, denies

hemoptysis, and denies tugging on her ears. She has received all vaccinations except for her

influenza vaccine. Emma has not received any OTC medications since her symptoms began. She

has had a decreased appetite but is still drinking liquids well. She has had several wet diapers and

has had normal stools. She woke up several times throughout the night with fussiness and crying.

Her mother states Emma has been exposed to sick children at the daycare and is exposed to

second-hand smoke in the home daily by both parents.

Past medical history:

Illness/ hospitalizations/ surgeries.

States generally in good health. No history of

hospitalizations. Normal full-term vaginal delivery. Breast-fed until 1 month of age and was then

provided formula.

Medications:

None

Allergies:

no known allergies

Preventative Health:

She has met all developmental milestones for her age. She has had

regular well checks.

Social history:

She lives in an apartment with her mother, father, and 5-year-old brother. Both

parents smoke in the home. They own one dog, a chihuahua that lives in the home. Her father is

a customer service representative, and her mother is an office manager. Both her paternal and

maternal grandparents live by for support.

Family history:

Father: 35 years old, mild intermittent asthma, uses albuterol as need, smoker

Mother: 31 years old, smoker

Brother: 5 years old, health