What three things do you think might pose a health risk

Nurse Practitioner 1: Hello, *Name*, what brings you here today?

*Name*: Hi. I want to know about birth control options. I have a boyfriend and sometimes when we, you know….

Nurse Practitioner 1: So, you and your boyfriend are having sex?

*Name*: Yes.

Nurse Practitioner 1: Are you using protection?

*Name*: Uh, we are. He does use a condom sometimes, but not always? I know we should, but … I just don’t want to get pregnant. That’s why I am here. I need birth control. Oh, we’re going on a vacation to Brazil. It’s my first time abroad and I’m sooo excited! Someone said I need to get a hepatitis vaccination? Can you explain what that is?

Nurse Practitioner 1: Let’s talk about your birth control options. And I will be happy to tell you what to expect with the hepatitis vaccination. I’ve never been to Brazil but my sister went last year and said the beaches were fantastic! First, let me take a look at your chart.

eMediChart

Patient: *Name*

Family HistorySocial HistoryCurrent MedsImmunization HistoryScreeningReview of SystemsPhysical ExamAssessment and Plan

Assessment and Plan

• Anticipatory guidance
• Immunization
• Screening recommendations

 

 

 

 

• Female, 18 years old
• Mother: diabetes mellitus, lupus
• Father: liver disease

Social History

• Does not smoke; occasionally uses marijuana; denies ETOH

Current Meds

• None

Immunization History

• Received TD in 7th grade at age 12
• Received 2 of the HPV vaccines but never got the third
• Received one Menactra at age 14

Screening

• Last pap: never had one
• Mammogram: never had one
• Colonoscopy: never had one
• Dexascan: never had one

Review of Systems

• General: no complaints of weight loss or gain
• HEENT: denies sore throat; nasal drainage, change in vision
• Resp: denies SOB, DOE, denies cough
• Cardiac: denies chest pain
• GYN: reports normal periods every 28–32 days. Last menstrual period was last week, denies any abnormal discharge or smell
• Skin: denies any changes to skin
• VS: 120/80, 88, 24, BMI 23

Physical Exam

• General: alert female in no apparent distress
• HEENT: pupils normal and reactive to light; TMs normal bilaterally, nares patent; throat without erythema or lesions
• Resp: normal rate and rhythm
• Cardiac: normal rate and rhythm
• GYN: normal vaginal rugae; normal ph, cervix without lesions;no cervical motion tenderness(CMT)
• Skin: warm and dry with no abnormalities

Assessment and Plan

• Anticipatory guidance

What three things do you think might pose a health risk?

Rank them in order.List at least three areas where health promotion counseling or anticipatory guidance would be appropriate.

 

• Immunization

 

• Screening recommendations

 

USE THE INFORMATION ABOVE TO ANSWER THE FOLLOWING QUESTIONS.

Screening and Immunization Case Study Example

Your Name: Example

Patient Name: Example

Make sure you use APA formatting for in-text citations and references, and have good sentence structure, grammar, spelling, and content of writing.

Things to Consider

• I am tired all the time, no energy, thirsty, polyuria, polydipsia, visual changes
• Her vital signs are stable, but she does have hypertension.
• BMI shows she is overweight.
• She states she drinks ETOH occasionally <3 drinks a week.
• She has a family history of diabetes, hyperlipidemia, and hypertension.
• She takes lisinopril and hydrochlorothiazide.
• Preventive care is not up to date (may need a mammogram).

Areas of Concern

1. Diabetes
2. Substance abuse
3. Kidney Disease
4. Thyroid disease
5. Obesity

What to Do

Primary Recommendations

1. Hepatitis B (if she has diabetes)
2. Seasonal flu
3. Pneumococcal (if she has diabetes)

Secondary Recommendations

1. Screen for ETOH abuse
2. Screen for hepatitis C
3. Screen for breast cancer
4. Screen for menopausal symptoms
5. Screen for depression

Tertiary Recommendations

1. Order a hemoglobin A1c
2. Adjust BP medications

Assessment and Plan

• She needs counseling on risk for diabetes.
• She needs counseling on ETOH use.
• She needs counseling on risk of coronary artery disease due to hypertension and family history.
• She needs counseling on obesity and strategies for weight reduction.

Three Scholarly Sources That Promote EBP

I used CDC for the immunization’s recommendations and USPTF for information on screening recommendations.  You may also use other sources such as UpToDate, American Diabetic Association, American Association of Endocrinology, etc. APA 7^th edition for any sources you used to include CDC, USPTF.

 

 

 

BELOW IS EXAMPLE TEMPLATE

 

Screening and Immunization Case Study

Your Name:

Patient Name:

Things to Consider

Complaints, vital signs, weight, social habits, co-morbidities, family history, medications areas of concern

List three things that come to mind as possible health problems in rank order.

What to Do

List at least three screening or immunization recommendations that apply to this patient in each category.

Go to Your Vaccine Assessment Results and enter information for your patient to get recommended immunizations and decide what is applicable based on what history you have.

Primary Recommendations

Secondary Recommendations

Tertiary Recommendations

Assessment and Plan

Anticipatory guidance: List at least three areas where health promotion counseling or anticipatory guidance would be appropriate.

Three Scholarly Sources That Promote EBP

Include CDC or USPTF if you used them for recommendations or other sources. Use APA 7th edition format.