As  part  of  a  specific  disease  prevention  program,  a  clinic  is  considering  setting  up  a

screening service in a town.  They are considering the following design:  After waiting in a

single line, each walk-in patient is served by one of three available nurses.  Each nurse has

their own booth, where the patient is first asked some medical health questions, then the

patient’s vitals are taken, and finally, a glucose test is performed to check for the disease.

In  this  design,  each  nurse  performs  the  tasks  in  sequence  for  the  patient.   If  the  glucose

test indicates a chance of the disease, the patient is sent to a separate clerk to schedule an

appointment for a follow-up at the clinic.  If the test is not positive, then the patient departs.

Patients’ are eager to get tested but they are reluctant to wait for to screening operations.

To clarify, if the number of people waiting for nurses is larger than 4, they prefer to go to

a park nearby the screening booths,  and spend 15 minutes therein.  After this 15 minute

period they again return to booths to check if the number of people is acceptable or not.

Noting that, there is no limit on the number of times for park visiting, i.e.  people are get

screened eventually.

Patients  arrive  to  the  system  according  to  an  exponential  distribution  with  a  mean

of  4  minutes.   Assume  that  there  is  a  5%  chance  that  the  glucose  test  will  be  positive.

For  the  given  design,  the  time  that  it  takes  to  have  the  paperwork  completed,  the  vitals

taken,  and  the  glucose  tested  are  all  lognormally  distributed  with  means  of  6.5,  6.0,  and

5.5 minutes, respectively.  They all have a standard deviation of approximately 0.5 minutes.

The  distribution  used  to  model  the  time  that  it  takes  to  schedule  a  follow-up  visit  is  a

WEIB(2.6, 7.3) distribution (in minutes).  Moreover, distance between park and screening

booths requires a travel time of uniformly distributed between 1 and 2 minutes.

In addition, nurses are working based on a schedule (valid for just nurses, not the clerk).

All breaks are given in a staggered manner that is, one nurse goes on break and immediately

upon  return  the  next  nurse  goes  on  break  until  all  nurses  have  had  their  breaks.   Nurses

are  kind  people,  hence  they  wait  until  the  patient  they  are  testing  is  done  and  returns

after  completing  their  scheduled  amount  of  time  for  the  breaks.   Assuming  the  screening

operations  start  at  8:00,  first  10  minute  breaks  should  be  given  starting  at  10:00.   Upon

completion  of  4  hours  of  work  (i.e.   at  12:00),  they  have  a  30  minute  lunch  break.   And

finally, at 15:00, they have one another small break session for 10 minutes.  The booths are

closed at 17:00.

•

Collect statistics for queue length, queue time and utilization of the resources for 30

replications.

•

State the average number of people screened as positive and negative.

•

What are the average cycle times for positive and negative patients

 

DERMATOLOGY CASE STUDY

Chief complaint:  “ My right great toe has been hurting for about 2 months and now it’s itchy, swollen and yellow. I can’t wear closed shoes and I was fine until I started going to the gym”.

HPI: E.D a 38 -year-old Caucasian female presents to the clinic with complaint of pain, itching, inflammation, and “yellow” right great toe. She noticed that the toe was moderately itching after she took a shower at the gym. She did not pay much attention. About two weeks after the itching became intense and she applied Benadryl cream with only some relief. She continued going to the gym and noticed that the itching got worse and her toe nail started to change color. She also indicated that the toe got swollen, painful and turned completely yellow 2 weeks ago. She applied lotrimin  AF cream and it did not help relief her symptoms. She has not tried other remedies.

Denies associated symptoms of fever and chills. 

PMH: Diabetes Mellitus, type 2.

Surgeries: None

Allergies: Augmentin

Medication: Metformin 500mg PO BID.

Vaccination History:  Immunization is up to date and she received her flu shot this year.

Social history: College graduate married and no children. She drinks 1 glass of red wine every night with dinner. She is a former smoker and quit 6 years ago.

Family history:Both parents are alive. Father has history of DM type 2, Tinea Pedis. mother alive and has history of atopic dermatitis, HTN.

ROS:

Constitutional: Negative for fever. Negative for chills.

Respiratory: No Shortness of breath. No Orthopnea

Cardiovascular: Regular rhythm.

Skin: Right great toe swollen, itchy, painful and discolored.

Psychiatric: No anxiety. No depression.

Physical examination:

Vital Signs

Height: 5 feet 5 inches Weight: 140 pounds BMI: 31 obesity, BP 130/70 T 98.0, P 88 R 22, non-labored

HEENT: Normocephalic/Atraumatic, Bilateral cataracts; PERRL, EOMI; No teeth loss seen. Gums no redness.

NECK: Neck supple, no palpable masses, no lymphadenopathy, no thyroid enlargement.

LUNGS: No Crackles. Lungs clear bilaterally. Equal breath sounds. Symmetrical respiration. No respiratory distress.

HEART: Normal S1 with S2 during expiration. Pulses are 2+ in upper extremities. 1+ pitting edema ankle bilaterally.

ABDOMEN: No abdominal distention. Nontender. Bowel sounds + x 4 quadrants. No organomegaly. Normal contour; No palpable masses.

GENITOURINARY: No CVA tenderness bilaterally. GU exam deferred.

MUSCULOSKELETAL: Slow gait but steady. No Kyphosis.

SKIN: Right great toe with yellow-brown discoloration in the proximal nail plate. Marked periungual inflammation. + dryness. No pus. No neuro deficit.

PSYCH: Normal affect. Cooperative.

Labs: Hgb 13.2, Hct 38%, K+ 4.2, Na+138, Cholesterol 225, Triglycerides 187, HDL 37, LDL 190, TSH 3.7, glucose 98.

Assessment:

Primary Diagnosis: Proximal subungual onychomycosis

Differential Diagnosis:  Irritant Contact Dermatitis, Lichen Planus, Nail Psoriasis

Special Lab:

Fungal culture confirms fungal infection.

As an NP student, you need to determine the medications for onychomycosis.

1. According to the AAFP/CDC Guidelines, what antifungal medication(s) should this patient be prescribed, and for how long? Write her complete prescriptions using the prescription writing format in your textbook.

2.  What labs for baseline and follow up of therapy would you order for this patient? Give rationale.

Apply the 3-Step Problem-Solving Approach

Use the Organizing Framework and the 3-Step Problem-Solving Approach to help identify inputs, processes, and outcomes relative to this case.

Step 1: Define the problem.

• Look first at the Outcomes box of the Organizing Framework (Figure 9.6) to help identify the important problem(s) in this case. Remember that a problem is a gap between a desired and current state. State your problem as a gap and be sure to consider problems at all three levels. If more than one desired outcome is not being accomplished, decide which one is most important and focus on it for Steps 2 and 3.
• Cases have key players, and problems are generally viewed from a particular player’s perspective. You need to determine from whose perspective—employee, manager, team, or the organization—you’re defining the problem.
• Use details in the case to determine the key problem. Don’t assume, infer, or create problems not included in the case.
• To refine your choice, ask yourself, why is this a problem? Explaining why helps refine and focus your thinking. Focus on topics in the current chapter, because we generally select cases illustrating concepts specifically located within the current chapter.

Step 2: Identify causes. Using material from this chapter and summarized in the Organizing Framework, identify what are the causes of the problem you identified in Step 1. Remember, causes tend to appear in either the Inputs or Processes boxes.

• Start by looking at the Organizing Framework (Figure 9.6) and decide which person factors, if any, are most likely causes of the defined problem. For each cause, explain why this is a cause of the problem. Asking why multiple times is more likely to lead you to root causes of the problem. For example, do employee characteristics help explain the problem you defined in Step 1?
• Follow the same process for the situation factors. For each ask yourself, why is this a cause? By asking why multiple times you are likely to arrive at a complete and more accurate list of causes. Again, look to the Organizing Framework for this chapter for guidance. Did particular policies or practices play a role?
• Now consider the Processes box in the Organizing Framework. Are any processes at the individual, group/team, or organizational level potential causes of your defined problem? For any process you consider, ask yourself, why is this a cause? Again, do this for several iterations to arrive at the root causes.
• To check the accuracy or appropriateness of the causes, be sure to map them onto the defined problem and confirm the link or cause and effect connection.

Step 3: Make your recommendations for solving the problem. Consider whether you want to resolve it, solve it, or dissolve it. Which recommendation is desirable and feasible?

• Given the causes you identified in Step 2, what are your best recommendations? Use material in the current chapter that best suits the cause. Consider the OB in Action and Applying OB boxes, because these contain insights into what others have done.
• Be sure to consider the Organizing Framework—both person and situation factors—as well as processes at different levels.
• Create an action plan for implementing your recommendations and be sure your recommendations map onto the causes and resolve the problem.

 Write a short story. Make sure the story follows the arc of a traditional story. It should have a distinct beginning, middle, and end. The story should contain an exposition, inciting incident, followed by rising action that builds to a climax. After the climax, the story should indicate some form of falling action leading to a resolution of some kind.

The story’s genre and subject matter are entirely up to you. Be sure, however, to consider and work in as many of the writing concepts as we’ve covered thus far in the course. Consider who your protagonist(s) and antagonist(s) will be. What is the conflict between them? What does each desire? What drives and motivates each? Consider, also, where these characters are and how that impacts the plot and story, as well as the language and details used. Put these characters in that setting and follow those parameters to their conclusions via your own imagination, creativity, and craft.

Keep the following guidelines in mind, too:

• The story must be a minimum of six pages in length.
• The story must include a title bearing conscious thought regarding its relation to the overall story.
• The story must be written in Times New Roman, 12-point font, double-spaced, with one-inch margins all around.
• The story must incorporate evidence of the writing concepts covered thus far in the course.

 Students will complete a 13-15 page research proposal paper. All work must be done according to APA style guidelines and formation, including a title page, introduction, background/significance, literature review, interview findings, action plan, proposed research design, recommendations, and references page.

• Research Paper Rubric Research Paper Rubric – Alternative Formats

The paper should include the following sections:

• Title Page
• Introduction: This should include an overview of the topic. Describe the focus of the paper, how you plan to approach it in your paper, and key elements the reader should look for.
• Background and Significance: This section provides the reader with an understanding of why the research is important.
• Literature Review: This review is the major part of the paper and will be 5-7 pages in length. It will be divided into sub-headings that identify the major issues and significant scholarly contributions to the topic. 
• Preliminary Interview Findings: This section will summarize your interview findings related to the “sticking point” you chose for your study.
• Five Point Action Plan: This section will apply Haydn Shaw’s five-point action plan model to the “sticking point” identified in your organization.
• Proposed Research Design: This section will recommend a specific approach to conduct formal research on the chosen topic. 
• Suppositions and Implications: Your initial reflection upon what you discovered in your readings on the topic and how they relate to your interviews with the five generational representatives. What conclusions have you reached regarding the generational sticking points and your organization? Include recommendations for any future study of the topic.
• Reference Page(s)