A Guide to Performing a Needs Assessment and a Gap Analysis
February 15, 2020
mental health patient
February 15, 2020

Sarah Smith is a 28 y/o African American female who presents to the office with c/o wound to her left foot for the past few days.

Assignment Details

For this assignment you will be given a case study about a young lady
named Sarah Smith. Review the information provided and answer the
questions following. Be sure to cite your references. Look at Sarah as
if she is a patient in your office seeking care. What are your immediate
concerns? What needs to be done for her? Be thorough and succinct in
your responses.

Case Study: 

Sarah Smith is a 28 y/o African American female who presents to the
office with c/o wound to her left foot for the past few days. States she
had tripped and fell while barefoot scraping the top of her foot on the
pavement. She denies any other injury from the incident. Over the past
24 hours the wound has had “smelly” drainage. Has been experiencing
generalized achiness, but denies fever and chills. Did not seek medical
attention at the time of injury. Has been using hydrogen peroxide to
clean her wound. Is unclear of her last tetanus vaccination. Patient
PMHx significant for DM II. States that she takes her medications when
she remembers, and does not always check her blood sugar.

PMHx:

Asthma: no hospitalizations for exacerbation.

DM II

PSHx:

Denies

SHx: 

Former tobacco user: ceased smoking 2 years ago. Had smoked 1ppd x 5 years

ETOH: socially

Illicit drugs: denies

FHx:

Significant for paternal DM, otherwise unremarkable

Medications: 

Metformin: 500mg BID po – did not take the last few days

Albuterol MDI: 2 puffs every 6 hours prn – last use just PTA

Singulair: 10mg po daily

Trinessa: 1 tab po daily – last taken this am

Allergies:

PCN: hives

LNMP: 2 weeks ago.

G0p0

ROS:

General: denies any weight changes, fatigue or fever; + body aches

Skin: denies any rashes; + wound to left foot

HEENT: denies headache, head injury, dizziness, lightheadedness;

            Denies any vision changes

            Denies any hearing changes, tinnitus, vertigo, earache

            Denies any nasal congestion, discharge, nose bleeds or sinus tenderness

            Denies any sore throat, difficulty swallowing

Neck: denies any swollen glands, pain

Breasts: denies any pain, discharge

Respiratory: denies any dyspnea; positive cough and wheezing

CV: denies any chest pain, edema

GI: denies any nausea/vomiting/diarrhea/constipation; denies bloody stools

PV: denies claudication, swelling to LE

GU: denies frequency, urgency, burning;

            Denies vaginal discharge, itching, sores

            Denies penile discharge, itching or sores

MS: positive pain to left foot

Psych: denies nervousness, depression

Neuro: denies Headache, dizziness, vertigo, syncope, weakness; + numbness to right LE

Heme: denies any easy bruising

Physical Exam:

Vital signs: 100.5 (tympanic), 162/88, 118, 22, O2 sat 95% on RA

                        Height: 5’5”     Weight: 250 lbs.

            Blood glucose: 230 (Fasting; states has not eaten yet today)

patient awake, alert, oriented x 4 in NAD

Skin: warm, dry, color WNL. 4 cm lesion noted to anterior left foot
with crusting and purulent drng; + surrounding erythema extending up 7
cm proximally

HEENT: head nontraumatic, normocephalic

Pupils PERRLA, EOMs intact; disc margins sharp, without hemorrhages, exudates; no AV nicking noted

Ears: bilateral TM with good cone of light and intact

Nose: mucosa pink, septum midline; no sinus tenderness appreciated

Mouth: mucosa pink, moist; tongue midline; tonsils 1+ without exudate

Neck: supple; trachea midline; no LAD

Resp: regular and unlabored; lungs with end expiratory wheezing throughout

CV: RRR, S1 and S2 noted; no s3, s4 or murmur appreciated

Abdomen: soft, non-distended; Bs + x 4; no tenderness with palpation; no CVA tenderness with percussion

Genitalia: deferred

Rectal: deferred

Extremities: warm and without edema; calves supple, non-tender

PV: no LE edema

MS: + swelling to left foot; + tenderness of 2-4th left metatarsals; + left pedal pulse; CMS intact; Cap refill < 2 sec.

Neuro: alert, cooperative; thought coherent; oriented x 4; cranial nerves II-XII intact

Questions:

1. List your differentials for her current problems. Remember you
should have at least three different differentials for each problem.
Include rationale for each differential.

2. At this time what medical diagnoses are you most concerned about? Do they impact other diagnoses? If so, how?

3. What diagnostic images would you order? Provide your rationale. What are you trying to rule in or out?

4. What laboratory work would you order? What would you anticipate to be abnormal? Provide your rationale for each.

5. What is your comprehensive plan of care? Include your rationales.

To view the Grading Rubric for this Assignment, please visit the Grading Rubrics section of the Course Resources.

Assignment Requirements

Before finalizing your work, you should:

  • be sure to read the Assignment description carefully (as displayed above)
  • consult the Grading Rubric to make sure you have included everything necessary; and
  • utilize spelling and grammar check to minimize errors.

Your writing Assignment should:

  • follow the conventions of Standard English (correct grammar, punctuation, etc.);
  • be well ordered, logical, and unified, as well as original and insightful;
  • display superior content, organization, style, and mechanics; and 

 

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