Evaluation plan
Assignment Details: Post an explanation of your Evaluation plan for the patient in the case study provided, and explain which type of assessment tool you might use for the patient. Explain whether the assessment tool was validated for use with this patient’s specific patient population and whether this poses issues. Include additional factors that might present issues when performing assessments, such as language, education, prosthetics, etc. Also explain the immunization requirements related to health promotion and disease prevention for the patient.
Mr. Sanchez, a 78-year-old retired postal worker, is in the office today for his annual physical exam. He is generally in good health, has a 10-year history of osteoarthritis. He is also requesting his annual influenza vaccination and inquiries about any other “shots” he may need. Watching him walk down the hall to the exam room you have noticed that he is using a cane in his left hand. When asked about this he states that the pain in his left knee has gotten considerably worse over the past 6 months.
VS: BP 132/60 Pulse 68 Resp 18 Temp 98.4 F O2SAT 98% on Room Air
PMH: Osteoarthritis, GERD
Allergies: NKDA
Medications:
• Omeprazole 20mg po daily
• Tylenol 500mg 2 tabs po TID PRN
• Volteran gel to left knee BID PRN
• Multivitamin 1 po daily
Social History: Retired postal worker, worked for 25 years as postal carrier then 15 years in the post office serving customers at desk. He is married with 2 adult children that live out of state. He drinks occasional alcohol, usually on weekends while watching sports. No smoking history, no illicit drug use.
ROS: Normal, with the exception of increasing pain in left knee
PE: Normal exam, with the exception of multiple seborrheic keratosis on his hands and face, his left
knee is slightly swollen, crepitation with passive ROM left knee.
Diagnostics/Assessments done: Left knee x-ray loss of cartilage.
Instructions:
Review the case study and based on the provided information, think about a possible patient evaluation plan. As part of your evaluation planning, consider where the evaluation would take place, whether any other professionals or family members should be present, appropriate assessment tools and guidelines, and any other relevant information you may wish to address.
Consider whether the assessment tool you identified was validated for use with this specific patient population and if this poses issues. Think about additional factors that might present issues when performing assessments such as language, education, prosthetics, missing limbs, etc.
Consider immunization requirements that may be needed for this patient.
Resources
Centers for Disease Control and Prevention. (2025). Recommended adult immunization schedule for ages 19 years or olderLinks to an external site.. https://www.cdc.gov/vaccines/hcp/imz-schedules/downloads/adult/adult-combined-schedule.pdf
Hartford Institute for Geriatric Nursing. (n.d.). General assessment seriesLinks to an external site.. In Try This: Series. Author. https://hign.org/consultgeri/try-this/general-assessment
U.S. Preventive Services Task Force. (n.d.). Information for health professionalsLinks to an external site.. https://www.uspreventiveservicestaskforce.org/uspstf/information-health-professionals
Gerontological Society of America. (2023). GSA enrich.Links to an external site. https://gsaenrich.geron.org/brain-health
Paper Format: APA
Number of pages: 1
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