NR511 week 6 case study

Guide to NR511 Case Studies (Week 3
& 6)

Part 1
In Part 1, you are given a patient scenario. Using the information given, answer the
following questions:

1.
Briefly and concisely summarize the H&P findings as if you were presenting it to your
preceptor using the pertinent facts from the case. Use shorthand where possible and approved
medical abbreviations. Avoid redundancy
and irrelevant information.

Example:

“J.S.
is a 34yo male with a CC of acute onset ST x 3 days” [provide additional
information from the history that is relevant].

“Physical
exam is significant for” [provide relevant physical exam findings].

*Do
not simply rewrite the information as it is presented in the case report. This
should mimic how you would present this patient to your preceptor.

2.
Provide a differential diagnosis (plural) which might explain the
patient’s chief complaintalong with a brief statement of pathophysiology for each.

Example:

Diagnosis
#1
-Pathophysiology
statement

Diagnosis
#2
-Pathophysiology
statement

Diagnosis
#3
-Pathophysiology
statement

3.
Analyze the differential by using the pertinent findings from the history and
physical to argue for or against a diagnosis.
Rank the differential in order of most likely to least likely.(This is where you present your argument for EACH DIAGNOSIS in your
differential using the patient’s subjective and objective information that was
given).

Example:

Diagnosis
# 1, 2, & 3 (provide an analysis for each of the diagnoses listed above)
A
brief argumentas to why this condition should be considered plus:
-Pertinent
positive symptoms which support the diagnosis
-Pertinent
negative symptoms which support the diagnosis

4.
Identify any additional tests and/or
procedures that you feel is necessary or needed to
help you narrow your differential. All
testing decisions must be supported with an EBM argument as to why it is
necessary or pertinent in this case. If
no testing is indicated or needed, you must also support this decision with EBM
evidence.(This is where you identify, based on what you know thus far, test or
test(s) that you would perform TODAY which would help you narrow your
differential diagnosis).

*Do
not list all of the possible tests that can be done. You are being evaluated on
your diagnostic reasoning skills as well your ability to make decisions that
are in-line with current practice recommendations. Just because a test is
available does not mean it needs to be done.

Example:

Let’s
say my differential included bronchitis and pneumonia. In this case, a CXR might be useful in
differentiating the 2 conditions.
However, remember that you have to have an EBM argument for this
decision. So make sure you are
telling the reader why this is the best choice based on the literature (i.e.,
it is not enough to say the test and cite the author & date). In this instance, my argument might look like
this: “According to the Infectious
Disease Society of America (2012) a CXR is considered the gold standard for
diagnosing pneumonia.” Keep in mind that
you also need an EBM argument if you decide NOT to test too.

Part 2
In Part 2 you might be given some additional history, exam or test
findings. Using this information and
the information in Part 1, answer the following questions:

1. What is your primary diagnosis for
this patient? Tell the reader how you came to this conclusion using the information
that you were given (i.e., CXR result, lab result). Interpret the results into your diagnosis
decision (i.e., tell how this information helped you to narrow your
differential to the one diagnosis that you chose).

Example:

Diagnosis:
Pharyngitis, streptococcal

Rationale:
The CBC
results are normal which rules out infection and anemia. The RSA test was +
which tells me that she has a very strong likelihood of streptococcal pharyngitis.

In the case where a diagnosis
was made based on clinical presentation and history, explain the criteria with an
EBM argument to support.

2.
Identify the corresponding ICD-10 Code for the diagnosis.

Example:

J02.0

You
can find a link to an ICD-10 code finder by going to the Library
homepage>Browse guides>Course directory tab>select NR511 from the drop
down box>select Go. Otherwise, a google search will provide you with several
free options you can use.

3.
Provide a treatment plan for this patient’s primary diagnosis which includes:

a) Medication-all prescriptions and
OTC medications should be written in RX format with an EBM to support:
Medication Name & Medication Strength
Dispensing quantity:
Sig:
RF:

b) Any additional testing necessary for this particular
diagnosis-typically done when you need more
information to confirm a diagnosis or differentiate the diagnosis. Do not state all of the possibilities that
are available. To assess your diagnostic reasoning skill, you will need to be
decisive.

c) Patient education-self
explanatory

d) Referral-self explanatory

e) F/U
plan-include if and when the patient should follow-up

*If
part of the plan does not warrant an action, you must explain why. ALL
medication and testing decisions (or decisions not to treat with medication or
additional testing) MUST be supported with an EBM argument as you did in Part
1.

Example:

a. Penicillin
VK 500mg, Disp #20, Sig: 1 tab twice daily x 10days; RF: 0 (full RX required)

Rationale: Penicillin
is the 1st line treatment recommendation for Group A Beta-hemolytic
streptococcal pharyngitis, based on their narrow spectrum of activity,
infrequency of adverse reactions, and modest cost. (Shulman, Bisno, Clegg, Gerber, Kaplan, Lee,
Martin, & Van Beneden, 2012). My
patient has no noted allergies, so PCN VK is appropriate.

b.
No additional testing will be
performed today.

Rationale: Point of care, rapid
strep antigen tests are highly specific (approximately 95%) when compared with
throat cultures, so false-positive test results are highly unusual. Consequently, a therapeutic decision can be
confidently made based on the positive result which was reported for this
patient in the scenario (Shulman, Bisno, Clegg, Gerber, Kaplan, Lee, Martin,
& Van Beneden, 2012).

c.
Patient instructions:
-take all medication as prescribed
(Reference, date)
-F/U
in 10-14 days if symptoms are not resolved or sooner if they become worse,
etc., (Reference, date)
-Etc..

4. Provide an active
problem list for this patient based on the information given in the case. This is where you list
all of the known medical problems of the patient. This is different than a differential.

Example:

1. Streptococcal
Pharyngitis
2. Hypertension
3. Obesity

List your references that were cited above according to APA rules.
Format is not graded (Canvas does a poor job in formatting the tabs and spaces)
BUT all other APA elements are required.

References

Shulman, S., Bisno, A., Clegg, H.,
Gerber, M., Kaplan, E., Lee, G., Martin, J., & Van Beneden, C. (2012). Clinical Practice Guideline for the Diagnosis
and Management of Group A Streptococcal Pharyngitis: A 2012 Update by Infectious Diseases Society
of America. Clinical Infectious Disease, 55(10), e89. DOI: 10.1093/cid/cis629Week 6:
Discussion Part One

A 56-year-old Caucasian female presents to the
office today with complaints of fatigue. Upon further questioning you discover
the following subjective information regarding the chief complaint.

History of Present
Illness

Onset

“about 2-3
months”

Location

Generalized

Duration

Constant

Characteristics

Progressively
worsening since onset, feels tired all of the time, sleeps 8hrs per night but
does not feel well rested. “No energy to do anything I normally can
do”

Aggravating factors

Exertion

Relieving factors

None identified

Treatments

None

Severity

Denies pain; missed
1 day of work 2 weeks ago because “couldn’t get out of bed”

Review of Systems
(ROS)

Constitutional

Denies fever,
chills, or recent illnesses. +5lb. weight gain since last visit 6 months ago.

Eyes

No visual changes or
diploplia

ENT

Denies ear pain,
coryza, rhinorrhea, or ST. Had tonsillectomy as child Denies snoring or
history of sleep apnea.

Neck

Denies lymph node
tenderness or swelling

Chest

Denies cough, SOB,
DOE or wheezing

Heart

Denies chest pain

Abdomen

Denies N/V/D. +
Constipation

Endocrine

Denies polyuria,
polydipsia. + cold intolerance. Menopause status x 5 yrs.

Skin

No changes in skin,
hair or nails

Psych

Reports worsening of
depressive symptoms but thinks it is because she is so
“unproductive” lately and tired all of the time. -Suicidal or
homicidal thoughts. Sleeping 8-9hrs per night (no changes), but not feeling
rested.

Musculoskeletal

Generalized weakness
and intermittent muscles cramping in calves

History

Medications

Multivitamin,
B-Complex, Prozac 20mg, Bisoprolol-HCTZ 2.5mg/6.25mg, Calcium 500mg + Vit D3
400IU.

PMH

HTN, Depression,
Postmenopausal status

PSH

Tonsillectomy

Allergies

Iodine dyes

Social

Married; Works full
time as office manager of an internal medicine office; 2 kids (grown)

Habits

Denies cigarettes or
drug use. +Occasional glass of wine (1-2 per month).

FH

Maternal GM & GF deceased with CHF, T2DM and HTN;
Mother alive (age 82) +HTN, +Hyperlipidemia, +T2DM;
Father alive (age 84) +HTN, +Hyperlipidemia, +T2DM, +ASHD (s/p
CABG 2 years ago). Also had +CVA at time of CABG (work-up revealed +DVT and
+PFO; remains anticoagulated);
Oldest child (26) with seasonal allergies
Youngest child (24)
with Bipolar depression and ADHD, and anxiety

Physical exam reveals the following:

Physical Exam

Constitutional

Middle aged
Caucasian female alert, oriented and cooperative

VS

Temp-98.2, P-74,
R-16, BP 146/95, Height: 5’7″, Weight: 180 pounds

Head

Normocephalic,
atraumatic

Eyes

PERRLA

Ears

Tympanic membranes
gray and intact with light reflex noted.

Nose

Nares patent. Nasal
turbinates without swelling. Nasal drainage is clear.

Throat

Oropharynx moist, no
lesions or exudate. Surgically removed tonsils bilaterally. Teeth in good
repair, no cavities.

Neck

Neck supple. No
lymphadenopathy. Thyroid midline, small and firm without palpable masses.

Cardiopulmonary

Heart S1 and s2
noted, no murmurs, noted. Lungs clear to auscultation bilaterally.
Respirations unlabored. No pedal edema

Abdomen

Soft, non-tender. BS
active

Skin

Skin overall dry,
hair coarse and thick, nails without ridging, pitting or discoloration

Psych

Mood pleasant and
appropriate.

Musculoskeletal

Strength full throughout

Neuro

DTRs 2+ at biceps,
1+ at knees and ankles

·
Briefly and concisely summarize the H&P findings as if you
were presenting it to your preceptor using the pertinent facts from the case.
Use shorthand where possible and approved medical abbreviations. Avoid
redundancy and irrelevant information.
·
Provide a differential diagnosis (minimum of 3) which might
explain the patient’s chief complaint along with a brief statement of
pathophysiology for each.
·
Analyze the differential by using the pertinent findings from
the history and physical to argue for or against a diagnosis. Rank the
differential in order of most likely to least likely.
·
Identify any additional tests and/or procedures that you feel is
necessary or needed to help you narrow your differential. All testing decisions
must be supported with an evidence-based medicine (EBM) argument as to why it
is necessary or pertinent in this case. If no testing is indicated or needed,
you must also support this decision with EBM.Week 6:
Discussion Part Two
Now, assume that you sent your patient for
labs and she returns the following day, as instructed, to review the results.
CBC with differential

WBC

8.6 x10E3/uL

RBC

4.44 x 10E6/uL

Hemoglobin

14.0 g/dL

Hematocrit

41.2%

MCV

93fL

MCH

31.5 pg

MCHC

34.0 g/dL

RDW

13%

Platelet

241 x 10E3/uL

Neutrophils %

67%

Lymphocytes %

22%

Monocytes %

8%

Eosinophils %

3%

Basophils %

0%

Absolute Neutrophils

5.7 x 10E3/uL

Absolute Lymphocytes

1.9 x 10E3/uL

Absolute Monocytes

0.7 x 10E3/uL

Eosinophils Absolute

0.3 x 10E3/uL

Basophile Absolute

0.0 x 10E3/uL

Immature Grans %

0%

Absolute Immature
Grans

0.0 x 10E3/uL

TSH with Reflex to FT4

TSH

6.770 uIU/mL

FT4

0.62 ng/dL

PHQ-9 Depression Score=10 (previous was 5 at
last visit 6 months ago)
·
What is your primary diagnosis for this patient as the cause for
the CC of fatigue? (support your decision for your diagnosis with pertinent
positives and negatives from the case)
·
Identify the corresponding ICD-10 code.
·
Provide a treatment plan for this patient’s primary diagnosis
which includes:
§ Medication*
§ Any additional testing necessary for this
particular diagnosis*
§ Patient education*
§ Referral and follow-up to the treatment plan
§ Provide an active problem list for this
patient based on the information given in the case.
·
Are there any changes that you would make to the patient’s
overall plan at this time? Must provide an evidence-based medicine (EBM)
argument to support any treatments or testing decisions.
·
Provide an appropriate follow-up plan (include any additional
testing that you feel is necessary and include an EBM argument).

*If part of the plan does not warrant an
action, you must explain why. ALL medication and testing decisions (or
decisions not to treat with medication or additional testing) MUST be supported
with an EBM argument. Over-the-counter (OTC) and RXs must be written in full as
if handing a script to the patient in the office.

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