Case study 3

Copy the template for ROS and PE from Bates verbatim and substitute normal for abnormal findings listed in the case studies. If the finding is normal put “denies”. If it is abnormal put “endorses”.

Use the pocket manual for differential diagnosis to look up your symptoms (presenting) and they will list possible causes. Narrow the causes down based on 1)your patient’s presenting symptoms and 2) by using the current medical diagnosis and treatment textbook.

Create a genogram for the family history. Example is in Bates.

Look at the case study rubric and make sure you’ve met all requirements.

Pertinent positive: sign/symptom that helps to rule in diagnosis.

Pertinent negative: sign/symptom that is NOT present and because it is not present helps to rule out an alternate diagnosis.

For example, pertinent positives for pneumonia could be fever and cough with blood-tinged sputum. These could also be pertinent positives for TB but if the patient does NOT have night sweats and weight loss for example, the absence of these symptoms would be pertinent negatives that would make you think the patient is more likely experiencing pneumonia (rule out TB).

GRADING SHEET FOR NUR 631 WRITTEN CASE STUDY

Student Name:
CCS# _1__

HISTORY DATA– 40 points HX pts____

Chief Concern (CC) (8) ____

Complete History of Present Illness (HPI) (12) ____

Pertinent PMH (meds, allergies, social risks) (4) ____

Review of Systems (Case data documented appropriately) (12) ____

Family History (with genogram) (4) ____

PHYSICAL EXAM – 40 points PE pts_____

Case data appropriately documented in

FULL
PE

DIFFERENTIAL DIAGNOSIS – 10 points DD pts____

List 3 Differentials to explain primary problem (3@1ea=3) ____

Give a brief
pathophysiologic description of each DD: (3)

Etiology ____

Usual clinical findings or features ____

Pertinent positives/negatives listed to support primary DD (2) ____

List additional history questions to support primary DD (1) ____

List additional physical findings to support primary DD (1) ____

PLAN OF CARE -5 points Plan pts___

(specific treatments including meds – be specific with doses, times)

Pharmacologic (2) ____

Non Pharmacologic (1) ____

Patient Education (1) ____

Follow Up (1) ____

*Neatness, typed, submitted on time, appropriate format,

use of appropriate terminology, references –
5 points Form pts___

Total points _____

Case Study 3: NUR 631 Lab

Felisha is a 34-year-old female with PMH of asthma, Hypertension, and dysmenorrhea, who presents to the clinic for evaluation of “abdominal pain.” She states it started 3 days ago. She denies any injury to her abdomen. She says it started by her belly button, then slowly moved to the RLQ and flank. Her partner Sally, said that on the way to the office, every pothole they drove over, she complained of pain. She took OTC Ibuprofen 600mg two days ago, but it just dulled the pain. She rates the pain currently 8/10 on the pain scale. She reports a low-grade fever of 37.8 Celsius yesterday but none today. She has intermittent nausea and admits to vomiting twice over the past 3 days. She works as a marine biologist, and it has been very hard for her to swim at work, so she had to call in today to get to the clinic. She has had decreased PO intake at home. She admits to smoking 3 cigarettes/day x 10 years. She drinks white wine socially. She has a mother (58yo HTN, CAD), father (62yo AFIB, CAD, CVA), Brother 26 (healthy). She takes amlodipine 5mg daily and uses albuterol inhaler as needed for her asthma control. She has had a PAP smear at age 32, and a LEEP procedure following with her gynecologist. She denies any urinary frequency, or blood in her urine. Her last BM was yesterday.

Vitals 36.8 oral, HR 98, BP 140/45, RR 18, SPO2 99% room air, Weight 157lbs, 5ft 9in

She is alert and oriented x 3. PERRLA, EOMI. Appropriate appearance. Oral mucosa dry, pink. Dentition in good repair. Neck supple, trachea midline, no lymphadenopathy, no JVD. Chest clear to auscultation. No pain to palpation of chest wall. Cardiovascular with normal s1, s2. No murmur or gallops appreciated. Abdomen is soft, BS X 4 quadrants. Pain with palpation of the right lower quadrant. No suprapubic tenderness. On GU exam, normal vaginal mucosa, cervical OS closed. LMP 2 weeks ago. Skin no rashes, no joint tenderness. No pedal edema is noted. ROM is intact in all joints bilaterally. Able to heel and toe walk. DTR’s 2+ BUE, BLE. Normal rectal tone, no hemorrhoids, Fecal occult blood negative.

CBC: WBC 21.6, HGB 13.5, HCT 29.0, PLTS 250

Chemistry: Na 135, K 3.5, Mag 2.0, BUN 27, Crea 0.9, glucose 114

Urine HCG: negative

Instructions: Reformat the above data as follows from Bates:

You must include a full ROS and Physical Exam for full Credit

1). CC:

HPI

PMH (include surgeries and traumatic injuries)

Current medications

Allergies

Psychosocial

Family History – genogram (you can draw it and place on last page, or create in word document)

ROS – complete information

Physical Exam – complete information

2). List 3 Differential Diagnoses in descending order of suspicion

(Number these as #1, #2, #3, your #1 should be your primary working DX)<