Diagnostic and Clinical Reasoning for Pediatric Pneumonia Paper

The purpose of this assignment is to provide you the opportunity to expand the scope of your clinical documentation and your thought processes relative to complex patient care cases.

Select a complex patient encounter that involves pediatric health issues.
The patient encounter you select should be one of the more complex patient cases that you have experienced with your current clinical patient population. Given that you are to select complex cases, this assignment may not be completed for a ‘general health, well child, routine physical exam (etc.)’ type of encounter. Please See attached for additional information. All requirements must be addressed.Must be in APA format

Please see attachments there are samples of a paper with teacher corrections

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The purpose of this assignment is to provide you the opportunity to expand the scope of your clinical documentation and your thought processes relative to complex patient care cases.

Select a complex patient encounter that involves women health issues.
The patient encounter you select should be one of the more complex patient cases that you have experienced with your current clinical patient population. Given that you are to select complex cases, this assignment may not be completed for a ‘general health, well child, well woman, routine OB, routine physical exam (etc.)’ type of encounter. Please See attached for additional information. All requirements must be addressed.Must be in APA format

Please look over comments and perhaps consult other examples of diagnostic reasoning papers that will help you write a more succinct, clear paper.
Please make the paper flow logically so that the reader can clearly see the progression. Consult other papers if you have access to examples.
Just make your working and final diagnoses clear and indicate what made you choose the tests that you chose and the treatments you chose.
There are several distracting grammar errors throughout this paper.
Usually this evaluation would include an ROS that addresses whether there is any vaginal discharge, itching or pain present.
The objective documentation of the vaginal GU exam is incomplete – there is no notation of the presence and position of the cervix and uterus. In addition there is not documentation of the bi-manual exam of the ovaries and whether they were able to be palpated or not. There is also no documentation of any discharge, irritation or the more detailed appearance of the vaginal and cervix. Typically there is documentation of whether or not there is cervical motion tenderness as well.
This section should include a list of all of your working diagnoses that are addressed through your diagnostic workup. You should have at least four differential diagnosis and then your final diagnosis. This seems to be out of sequence in the paper with the table. However the table addition showing your working diagnoses was a fortunate addition to your paper.
In reviewing your plan I do not see the diagnosis for which you are treating this patient. In fact I am not sure where your plan begins. It appears that it is under the heading “therapeutic.” What diagnosis are you treating with the estradiol? “Progesterone will also be given to treat some problems with the uterus.” What does this mean? What do you mean by “some problems.” This should be concisely articulated instead of your statement so that the reader knows exactly what you are referring to.
Your differentials and treated diagnosis should be listed out clearly and designated clearly with each one identified with the corresponding workup and reasoning. It appears that this is out of sequence in your paper and appears under the heading “priority diagnosis discussion.”

My suggestion is to keep your sections of your paper in the order of the rubric.
The clinical decision making heading should list why the treatments chosen for the diagnosis were chosen and how you came to these conclusions. Unfortunately your paper under this heading goes straight into pathophysiology – but is not flowing and explaining the basis for clinical decision making. Parts of the plan appear to be in this section with the pharmacology entries.
Your paper reflects evidence based practice with plenty of documentation on the treatments for the differential diagnosis – however I can’t tell the exact diagnosis you are treating as it is not clearly articulated with the accompanying clear articulation of the corresponding treatment.
My suggest is that you format your papers with more clarity for your final diagnosis and then list our the rest of your differentials. When designating your final diagnosis I suggest you indicate it clearly along with the corresponding plan.