Poor Patient Outcome

Relying solely on the classic features of a disease may be misleading. That’s because the clinical presentation of a disease often varies: the symptoms and signs of many conditions are non-specific initially and may require hours, days, or even months to develop.

Generating a differential diagnosis; that is, developing a list of the possible conditions that might produce a patient’s symptoms and signs — is an important part of clinical reasoning. It enables appropriate testing to rule out possibilities and confirm a final diagnosis.

This case portrays a poor patient outcome after a misdiagnosis.

Case scenario

A previously healthy 35-year-old lawyer presents to a primary care office with a chief complaint of chest pain and a non-productive cough. The pain started suddenly 2 hours prior to coming to the office while the patient was sitting at his desk. The patient describes the pain as sharp in nature, constantly present but made worse with inspiration and movement, and with radiation to the base of the neck. His blood pressure in the right arm and other vital signs are normal.

On physical examination the only findings of note are chest wall tenderness and a faint cardiac murmur. The ECG in the office is normal. The patient is observed for an hour in the office and assessed. He is diagnosed with viral pleurisy and sent home on non-steroidal analgesics.

The following day the patient collapses at home and cannot be resuscitated by the paramedic service. An autopsy reveals a Type 1 aortic dissection with pericardial tamponade.

Written Assignment:

Developing a list of possible conditions that might produce a patient’s symptoms and signs is an important part of clinical reasoning.

1. As an NP in primary care what would you have done differently?
2. Discuss the importance of creating a list of differentials for this patient. How could it have changed this outcome?

If a serious diagnosis comes to mind based on a patient’s symptoms:

• Ask yourself; Have you considered the likelihood of it and whether it needs to be ruled out by testing or referral?
• Because many serious disorders are challenging to diagnose, have you considered ruling out the worst case scenario?
• Ask yourself: Do you have sufficient understanding of the clinical presentation to offer an opinion on the diagnosis?
• What other diagnosis could it be? How might the treatment to date have altered the patient outcome?
• What other diagnostic and laboratory or imaging was needed in order to make a complete differential list?  What support tools would you consider using in helping to create a differential diagnosis list?
• Are you familiar with the current clinical practice guidelines for the investigation of a suspected condition such as chest pain?
• 5 pages

 

Using the client family from your Week 3 Practicum Assignment, address in a progress note (without violating HIPAA regulations) the following:

• Treatment modality used and efficacy of approach
• Progress and/or lack of progress toward the mutually agreed-upon client goals (reference the treatment plan for progress toward goals)
• Modification(s) of the treatment plan that were made based on progress/lack of progress
• Clinical impressions regarding diagnosis and or symptoms
• Relevant psychosocial information or changes from original assessment (e.g., marriage, separation/divorce, new relationships, move to a new house/apartment, change of job)
• Safety issues
• Clinical emergencies/actions taken
• Medications used by the patient, even if the nurse psychotherapist was not the one prescribing them
• Treatment compliance/lack of compliance
• Clinical consultations
• Collaboration with other professionals (e.g., phone consultations with physicians, psychiatrists, marriage/family therapists)
• The therapist’s recommendations, including whether the client agreed to the recommendations
• Referrals made/reasons for making referrals
• Termination/issues that are relevant to the termination process (e.g., client informed of loss of insurance or refusal of insurance company to pay for continued sessions)
• Issues related to consent and/or informed consent for treatment
• Information concerning child abuse and/or elder or dependent adult abuse, including documentation as to where the abuse was reported
• Information reflecting the therapist’s exercise of clinical judgment

Note: Be sure to exclude any information that should not be found in a discoverable progress note.

Part 2: Privileged Note

Based on this week’s readings, prepare a privileged psychotherapy note that you would use to document your impressions of therapeutic progress/therapy sessions for your client family from the Week 3 Practicum Assignment.

In your progress note, address the following:

• Include items that you would not typically include in a note as part of the clinical record.
• Explain why the items you included in the privileged note would not be included in the client family’s progress note.
• Explain whether your preceptor uses privileged notes. If so, describe the type of information he or she might include. If not, explain why.

Please develop a marketing plan for a healthcare facility that was recently cited by the OIG (Office of Inspector General), or has been investigated by a journalist (eg., newspaper article, journal). The marketing plan must include a cover page, reference page and must be completed using Microsoft PowerPoint. 

Please answer the following items in your marketing plan: minimum 8 slides 

1. Organizational Summary – Explain why the company is in trouble
2. Analysis of the External Environment – (Public perception, economy)
3. Threats and Opportunities                                                           
4. Marketing Goals and Objectives                                     
5. The Target Market
6. Competition – List possible competitors                                                
7. Marketing Strategy                                                            
8. Action Programs (Marketing tactics)                         
9. Budgets – How much money do you think this would cost?

Critically analyse the human factors that influence the successful implementation of electronic health record systems

This is a ‘standard’ academic essay which should be based on wide reading. The subheadings will make themselves known as you read.  They are likely to include factors such as 

·  staff acceptance

·  management support

·  leadership

·  selecting ‘champions’ or influential users

Maximum 2,000 words