NR511 week 3 case study part one and part two 2018

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 complaint along 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 argument as 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/cis629

Part one

A 19-year-old male freshman college student presents to the student health center today with complaints of bilateral eye discomfort. Upon further questioning you discover the following subjective information regarding the chief complaint.

History of Present Illness

Onset

2-3 days ago

Location

Both eyes

Duration

Constant

Characteristics

Both eyes feel "gritty" with mild to moderate amount of discomfort. Further describes the gritty sensation "like sand caught in your eye"

Aggravating factors

None identified

Relieving factors

None identified

Treatments

Tried OTC visine drops yesterday which temporarily improved the redness but the gritty sensation, tearing and itching remained.

Severity

Level of discomfort is 2/10 on pain scale

Review of Systems (ROS)

Constitutional

Denies fever, chills, or recent illnesses

Eyes

Denies contact lenses or glasses, has never experienced these symptoms previously. Last eye exam was "a few years ago". Denies recent trauma or eye injury. Denies crusting of lids or mucoid or purulent drainage. Bilateral symptoms of +redness, +itching, +tearing + FB sensation.

Ears

-otalgia, -otorrhea

Nose

+occasional runny nose with intermittent nasal congestion, denies sneezing. History of seasonal nasal allergies which is aggravated in the spring but is well controlled on loratadine and fluticasone nasal spray taken during peak season.

Throat

Denies ST and redness

Neck

Denies lymph node tenderness or swelling

Chest

Denies cough, SOB and wheezing

Heart

Denies chest pain

History

Medications

Loratadine 10mg daily and fluticasone nasal spray daily (only takes during the spring months when nasal allergies flare)

PMH

Seasonal allergic rhinitis with springtime triggers

PSH

None

Allergies

None

Social

Freshman student at the University of Awesome located in central Illinois. Home is in Phoenix.

Habits

Denies cigarettes +recreational marijuana use +drinks 3-6 beers per weekend

FH

Adopted, does not know biological parents history

Physical exam reveals the following.

Physical Exam

Constitutional

Young adult male in NAD, alert and oriented, cooperative

VS

Temp-97.9, P-68, R-16, BP 120/75, Height 6'0, Weight 195 pounds

Head

Normocephalic

Eyes

Visual Acuity 20/20 (uncorrected) OU. PERRL with white sclera bilaterally. + photosensitivity. No crusting, lesions or masses on lids noted. Bilateral conjunctiva with diffuse redness and tearing but no mucoid or purulent drainage noted. No visible FBs under lids or on cornea to gross examination.

Fundiscopic examination: Discs flat with sharp margins. Vessels present in all quadrants without crossing defects. Retinal background has even color, no hemorrhages noted. Macula has even color.

Ears

Tympanic membranes gray and intact with light reflex noted. Pinna and tragus nontender.

Nose

Nares patent. Nasal turbinates are pale and boggy with mild to moderate swelling. Nasal drainage is clear.

Throat

Oropharynx moist, no lesions or exudate. Tonsils ¼ bilaterally. Teeth in good repair, no cavities noted.

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.

· Briefly and concisely summarize the history and physical (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 evidence.

Part two

Now, assume that any procedures and/or testing which were performed are NORMAL.

· What is your primary (one) diagnosis for this patient at this time? (support the 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.

*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 evidence-based medicine (EBM) argument. Over-the-counter (OTC) and RXs must be written in full as if handing a script to the patient in the office.