NRNP 6531 – i-Human Management Plan Study Guide

NRNP 6531 – i-Human Management Plan Study Guide

NRNP 6531 i-Human Assignment:

ASSIGNMENT INSTRUCTIONS:

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  • Open and carefully review the i-Human case. This will provide the HPI, history, and physical exam findings needed for your assignment.
  • Complete the full i-Human case, including identifying Key Findings, creating a Problem Statement, selecting and ranking Differential Diagnoses, choosing and reviewing tests, and confirming your Primary Diagnosis. This process will prepare you to complete your Management Plan.
  • Download the template below, then copy and paste it into a Word document. Complete all sections, keeping the original headings and order. Ensure formatting is clear, organized, and easy to read.
  • Submit your Word document to Turnitin to check for originality. Once complete, upload the final version to the assignment submission link in Canvas.
  • Important: Failure to follow these instructions will result in a grade of “0” for the assignment.

 

MANAGEMENT PLAN TEMPLATE

 

PROBLEM STATEMENT:

Write a Problem Statement in paragraph format. Keep in mind, this is not the same as an HPI (History of Present Illness) or a SOAP note.  A Problem Statement is how you would present a patient case to your preceptor. It should include both subjective and objective data and clearly explain how you arrived at the primary diagnosis.  Be specific. Include relevant details such as the patient’s history, vital signs, lab results, and physical exam findings—any information that supports your clinical reasoning and diagnosis.  As you write, imagine you are verbally presenting this case to your preceptor. Your goal is to provide a clear, evidence-based explanation for your diagnosis.

PRIMARY DIAGNOSIS:

 

Name of Primary Diagnosis (ICD-10 code).  State the primary diagnosis for the case and include he associted ICD-10 code.  After, in paragraph format, include definition of the primary diagnosis, causes, usual presenting symptoms and end your paragraph by clearly explaining your rationale for determining it is your primary diagnosis as it relates to the patient case. Ensure you include in-text citations throughout (ABC, 2023).

Example:

Streptococcal Pharyngitis (J02.0).  Streptococcal pharyngitis, commonly known as strep throat, is an acute infection of the oropharynx caused by Group A beta-hemolytic Streptococcus (GAS), specifically Streptococcus pyogenes (CDC, 2023). It is a contagious bacterial infection that primarily affects the throat and tonsils. Strep throat is most common in school-aged children but can occur in adults as well. The infection is typically spread via respiratory droplets or direct contact with nasal secretions from an infected individual (Mayo Clinic, 2022).  The most common symptoms include a sudden onset of sore throat, fever, painful swallowing, swollen and tender anterior cervical lymph nodes, and pharyngeal or tonsillar erythema with or without exudate. Unlike viral pharyngitis, strep throat typically does not present with cough, rhinorrhea, or hoarseness (Shulman et al., 2012). Some patients may also experience headache, abdominal pain, or nausea. In this patient’s case, the diagnosis of streptococcal pharyngitis is supported by both clinical presentation and diagnostic testing. The patient reported a sore throat, fever, and difficulty swallowing. On physical examination, the tonsils were erythematous with white exudates, and there was tenderness of the anterior cervical lymph nodes. The patient did not report a cough or nasal congestion, which further supports a bacterial rather than viral etiology. Most importantly, a rapid strep point-of-care test (POCT) performed during the visit was positive, confirming the presence of Group A Streptococcus. Given the constellation of symptoms, exam findings, and the positive POCT result, streptococcal pharyngitis (J02.0) is the most appropriate primary diagnosis (CDC, 2023; Shulman et al., 2012).

CLINICAL GUIDELINE USED:

List the evidence-based clinical practice guideline(s) that support your primary diagnosis and treatment plan. Include the year, author/organization, and full title of the guideline (e.g., 2017 AHA/ACC Guideline for the Prevention, Detection, Evaluation, and Management of High Blood Pressure in Adults).

After listing the guideline(s), write a brief paragraph explaining how they informed your diagnostic reasoning. Highlight key diagnostic criteria and any recommended assessments used to support your decision.

Be sure to include in-text citations (e.g., ABC, 2023) and cite the full guideline in your reference list at the end of the template.

 

DIFFERENTIAL DIAGNOSES: (List at least 3, max 5)

 

  1. Name of Differential Diagnosis #1 (ICD-10 code). Include definition, causes, usual presenting symptoms. End your paragraph by explaining how you have ruled it out as the primary diagnosis.  List any references to support your reasoning at the end of this template and include any in-text citations here (ABC, 2023).

 

  1. Name of Differential Diagnosis #2 (ICD-10 code). Same requirements as above.

 

  1. Name of Differential Diagnosis #3 (ICD-10 code). Same requirements as above.

 

LABS, PROCEDURES, DIAGNOSTIC TESTING, REFERRALS, & CODES USED FOR TODAYS VISIT:

 

  1. Office Visit Code (Level of Service) – 99212

 

  1. Procedures/Testing:

 

  1. Urinalysis – 81001
  2. CMP – 80053
  3. 12 lead ECG – 93000
  4. Abdominal Ultrasound – 76700
  5. Chest X-ray (PA+lateral) – 71046

 

  1. Referral to Cardiology for irregular heartbeat

 

 

MEDICATIONS:

List all new prescriptions and OTC medications you are recommending today. Include the medication name, dose, frequency, and purpose.  Also, list any current medications the patient should continue, with the same details.  If you are not prescribing or recommending any new medications, clearly note that under the “Medications” heading.  See the example below for formatting.

  1. New Prescription Medication(s):

 

Lisinopril 10mg tablet.  Take 1 tab daily for HTN

 

  1. Stop taking the following medication(s):

 

Ibuprofen 800 mg tablet every 8 hours for pain

 

  1. Continue to take previously prescribed medications as directed below:

 

Metformin 1000 mg twice daily for type 2 diabetes

Atorvastatin 20 mg once daily for high cholesterol

OTC Ibuprofen 400 mg every 8 hours as needed for pain relief

OTC Diphenhydramine 25 mg every 12 hours as needed for allergies or sleep aid

 

SOCIAL DETERMINANTS OF HEALTH (SDOH):

  1. Education and Literacy:
    • John completed high school but did not pursue higher education.
    • He can read and write proficiently.
    • Limited knowledge of health-related topics beyond basic understanding.
  2. Employment and Income:
    • Currently employed full-time as a sales associate.
    • Income is stable but limited, struggles to afford healthcare expenses at times.
  3. Housing and Neighborhood:
    • Lives in a rented apartment in a suburban area.
    • The apartment is in good condition with no significant environmental hazards.
    • Neighborhood is relatively safe but lacks access to parks or recreational facilities.
  4. Social Support and Relationships:
    • Married with two children.
    • Supportive family structure, though some stress related to financial concerns.
  5. Access to Healthcare:
    • Has health insurance coverage through employer, but copays and deductibles pose financial challenges.
    • Accesses primary care regularly but has delayed seeking specialty care due to cost concerns.

SDOH Plan:

  1. Connect John with resources for financial assistance programs to help alleviate healthcare-related financial burdens.
  2. Provide education and resources on healthy eating within budget constraints.
  3. Explore options for transportation assistance to ensure consistent attendance at healthcare appointments.
  4. Regularly assess and address any emerging social needs to promote John’s overall health and well-being.

 

HEALTH PROMOTION:

  1. List recommended screening exams based on the patient’s age, sex, and risk factors in a numbered format. These screenings are not limited to the chief complaint.
  2. Use the S. Preventive Services Task Force (USPSTF) website to identify appropriate screenings.
  3. Include in-text citations for each recommendation and add the full reference in the References section (U.S. Preventive Services Task Force, 2024). See format to follow below in #4-6.
  4. Recommend prostate screening/PSA (U.S. Preventive Services Task Force, 2024)
  5. Recommend diabetes screening/A1C (U.S. Preventive Services Task Force, 2024)
  6. Recommend behavioral counseling – for diet, physical activity, and weight loss (U.S. Preventive Services Task Force, 2024)

 

PATIENT RISK FACTORS:

 

  1. Patient risk factors should include a list of risk factors related to the primary diagnosis. Include in-text citation to support your work and add those references to the end within the ‘Reference’ section (ABC, 2024).
  2. Example: Patient admits to lack of exercise, unhealth eating, and is a current 1 pack a day cigarette smoker.  These put the patient increase risk for cardiovascular disease (LMN, 2024).

 

 

 

PATIENT EDUCATION:

 

  1. Provide clear, evidence-based, comprehensive patient education on the primary diagnosis, treatment plan, medication use, lifestyle modifcation, and symptom management. Use in-text citations as appropriate (ABC et al., 2024).
  2. Provide education on the patients primary diagnosis to include: disease definition, common causes, and red-flag symptoms to watch out for (ABC, 2023).
  3. Include any additional education related to the treatment plan, such as instructions for new medications, their purpose, and common side effects (EFG, 2024).
  4. Write the education as if speaking directly to the patient. Be specific—do not write vague statements like “Educate patient on HTN.” Instead, explain what the diagnosis means and what the patient needs to know. Example: “Today, you were diagnosed with high blood pressure. This means…” (ABC et al., 2024).

 

FOLLOW-UP INSTRUCTIONS:

Provide specific and patient-directed follow-up instructions. Include who the patient is following up with, when, and clear reasons to return sooner (avoid vague phrases like “if symptoms worsen”). If a referral was made, restate it here with contact details and next steps.

Format to Follow:

  • Follow up with Dermatology in 2 weeks. Referral was placed today; NC Dermatology will contact you to schedule. If you don’t hear from them in 2 days, call XXX-XXX-XXXX.
  • While waiting for your appointment, follow up sooner with our clinic for any lesion changes—such as bleeding, pain, redness, or swelling.
  • Follow up in 3 months at this office for your annual wellness visit. Return sooner for any new or worsening concerns.

 

REFERENCES: 

Include at least 3 scholarly, peer-reviewed sources, all published within the last 5 years. Include the clinical guideline(s) used to support your diagnosis and treatment plan.  All references must be in APA format.  Do not use non-scholarly sources such as textbooks, STATPearls, UpToDate, MayoClinic.org, or ClevelandClinic.org.

Example:

American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines. (2017). Clinical practice guideline for high blood pressure in adults. https://www.exampleurl.com

Smith, J. A., Doe, A. B., & Johnson, C. D. (Year). Epidemiology of hypertension: A comprehensive review. Journal of Hypertension Research, 10(3), 123–135. https://doi.org/xx.xxx/yyyy

Brown, K. L., Jones, M. P., & Patel, R. H. (Year). Role of angiotensin-converting enzyme inhibitors in hypertension management: A systematic review. Journal of Clinical Pharmacology, 25(2), 67–79. https://doi.org/xx.xxx/yyyy

Type 2 Diabetes Mellitus (Adult Primary Care Case)

🩺 Diagnosis

Primary Diagnosis: Type 2 Diabetes Mellitus (uncontrolled)
A1C: 8.6%

1️⃣ Diagnostics

Baseline / Ongoing Monitoring:

  • Hemoglobin A1C every 3 months until controlled

  • CMP (renal & liver function)

  • Urine albumin-to-creatinine ratio (nephropathy screening)

  • Fasting lipid panel

  • Vitamin B12 level (if long-term metformin use)

  • Dilated eye exam referral

  • Foot exam (performed today + annually)

2️⃣ Pharmacologic Management

First-Line Therapy

Metformin 500 mg PO twice daily with meals

  • Increase to 1000 mg BID as tolerated

  • Rationale: First-line per ADA guidelines unless contraindicated

  • Avoid if eGFR <30

If A1C remains above goal (>7%) after 3 months:

Consider adding:

  • GLP-1 receptor agonist (if ASCVD risk or obesity)

  • SGLT2 inhibitor (if CKD or heart failure risk)

(Only include add-ons if case supports it — don’t over-treat in i-Human.)

If Hypertension Present:

Lisinopril 10 mg PO daily (renal protective)

If Hyperlipidemia Present:

Atorvastatin 20–40 mg PO daily (moderate-to-high intensity statin)

3️⃣ Non-Pharmacologic Management

  • Medical nutrition therapy referral

  • Carbohydrate-controlled diet

  • Weight loss goal: 5–10% body weight

  • Exercise: ≥150 minutes/week moderate aerobic activity

  • Resistance training 2–3 times/week

  • Smoking cessation if applicable

  • Limit alcohol intake

4️⃣ Patient Education

Discussed:

  • Nature of diabetes as chronic condition

  • Importance of medication adherence

  • Home blood glucose monitoring (fasting goal 80–130 mg/dL)

  • Signs of hypoglycemia:

    • Sweating

    • Shaking

    • Confusion

  • 15–15 rule for low blood sugar

  • Foot care:

    • Inspect daily

    • Proper footwear

  • Importance of annual eye exams

Patient verbalized understanding.

5️⃣ Preventive Care

  • Influenza vaccine annually

  • Pneumococcal vaccine (if indicated)

  • Hepatitis B vaccination (if not previously immunized)

  • Statin therapy per age/risk

  • Aspirin if ASCVD risk appropriate

6️⃣ Follow-Up Plan

  • Follow-up in 3 months for repeat A1C

  • Return sooner for:

    • Blood glucose >300

    • Hypoglycemia episodes

    • Chest pain

    • Shortness of breath

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