Mr. C, a 64 year-old faculty member teaching computer science, presents with headache, weakness, and numbness on his left extremities.
Assignment Details: Scenario:
Mr. C, a 64 year-old faculty member teaching computer science, presents with headache, weakness, and numbness on his left extremities. He’s by himself and a little confused, so his history is “sketchy.”
CC: “I had these problems this morning. I then seemed to improve, and then got worse. Now I’m getting scared.”
Past medical history: Hypertension, possible transient ischemic attacks s last year per verbal history (patient was on vacation). Has been taking ASA 81 mg and amlodipine (Norvasc) 10 mg daily.
Physical exam: Blood pressure, 162/96; respiration rate, 26/min. Patient awake but confused, left foot slightly externally rotated, difficulty walking, bilateral high-pitched carotid bruits, decreased sensation in left lower extremity.
Questions:
These are questions to assist you with research, use the rubric to set up the paper.
1. What additional subjective data do you think the patient will share?
2. What additional objective data will you be assessing for?
3. What National Guidelines are appropriate to consider? What level of evidence supports these guidelines?
4. What tests will you order?
5. Will you be looking for a consult?
6. What are the medical and nursing diagnoses?
7. Are there any legal/ethical considerations?
8. What is your plan of care?
medical
nursing
complementary therapies
9. Are there any Healthy People 2030 objectives that you should consider?
10. Using the Circle of Caring, what or who else should be involved to truly hear the patient’s voice, getting him and the family involved in the care to reach optimal health?
11. What additional patient teaching is needed?
12. What billing codes would you recommend?
Please include:
assessment
guidelines/Evidence
Diagnostics
Treatment Plan
Evaluation
Healthy People 2030
Health Promotion
Patient/Family Teaching
Billing (CPT codes)
Follow up
Paper Format: APA
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