09 Nov Felisha is a 34-year-old female with PMH of asthma, Hypertension, and dysmenorrhea, who presents to the clinic for evaluation of abdominal pain.? ?Instructor.docxRubric631_Cases_3.docxCaseS

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).

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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 ([email protected]=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 _____

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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)

3). List the pertinent positives/negatives to support your differentials. (at least 3 of each)

4). List additional history data that would support your primary differential diagnosis and why? (At least 10 history questions listed)

5). List any additional physical components that would support your primary differential diagnosis and why? (At least 5 PE findings that would better help you diagnose your primary differential)

6). Select your primary differential diagnosis as #1 and include 2 other differentials:

a) Give a brief pathophysiologic description of each disorder (< 10 sentences)

b) Etiology (primary dx)

c) Usual clinical findings or features (primary dx)

d) Diagnostic criteria (if any) for making the diagnosis (primary dx)

e) Treatment Plan – include specific treatments like pharmacotherapy (be specific with doses, amounts, etc) (for your PRIMARY DX)

The

Basic 7 Questions

1. Where is it located? Where does it hurt the worst?2.

2. Quality: What do you bring up when you cough? How would you describe the pain? What does it feel like?

3. Severity: How bad is it?

4.Context: How did it happen? When do you notice it?5.

5. Timing: When did it start? or how long have you had it? How frequently does it happen?6.

Modifying factors:

6. What makes it better? or What have you done about it? What makes it worse?7.

7. Associated symptoms: What other symptoms are you having

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-General  Usual weight, recent weight change, weakness, fatigue, or fever

-Skin    Rashes, lumps, sores, itching, dryness, changes in color, changes in hair or nails, changes in size or color moles 

-Head, Eyes, Ears, Nose, Throat (HEENT):  

– Head: Headache, head injury, dizziness, lightheadedness. Eyes: Vision, glasses or contact lenses, pain, redness, excessive tearing, double or blurred vision, spots, specks, flashing lights, glaucoma, cataracts. Ears: Hearing, Tinnitus, Vertigo, earaches, infection, discharge, If hearing is decreased, use or nonuse of hearing aids, Nose and Sinuses: Frequent colds, nasal stuffiness, discharge, or itching, hay fever, nose- bleeds, sinus trouble. Throat ( or mouth and Pharynx): Condition of teeth and gums, bleeding gums, dentures, if any, and how they fit, sore tongue, dry mouth, frequent sore throats, hoarseness.

-Neck  “Swollen Glands,” goiter, lumps, pain, or stiffness in the neck. 

-Breast  Lumps, pain, or discomfort, nipple discharge

-Respiratory  Cough, sputum (color quantity; presence of blood or hemoptysis), shortness of breath (dyspnea), wheezing, pain with a deep breath (Pleuritic pain).

-Cardiovascular  “Heart trouble”; high blood pressure; rheumatic fever; heath murmurs; chest pain or discomfort; palpitations; shortness of breath; need to use pillows at night to ease breathing (orthopnea); need to sit up at night to ease breathing (paroxysmal nocturnal dyspnea) swelling in the hands , ankles, or feet (edema). 

-Gastrointestinal  Trouble swallowing, heartburn, appetite, nausea. Bowel movements, stool color and size, change bowel habits, pain constipation, diarrhea. Abdominal pain, food intolerance, excessive belching or passing of gas. Jaundice, liver, or gallbladder trouble. 

-Peripheral Vascular  Intermittent leg pain with exertion (Claudication); leg cramps; varicose veins; past clots in the veins; past clots in the veins; selling in claves, legs, or feet; color change in fingertips or toes during cold weather; selling with redness or tenderness.

-Urinary  Frequency or urination,  polyuria, nighttime urination (nocturia), urgency, burning or pain during urination, blood in the urine (hematuria), urinary infections, kidney or flank pain, kidney stones, ureteral colic, suprapubic pain, incontinence;  in males, reduced caliber or force of the urinary stream, hesitancy, dribbling. 

-Genital  

Male: Hernia, discharge from or sores on the penis, testicular pain or masses, scrotal pain or swelling, history of sexually transmitted infection and their treatments. Sexual interest (Libido), function, satisfaction

Female: Menstrual regularity, frequency, and duration of periods, amount of bleeding; bleeding between periods or after intercourse, dysmenorrhea, premenstrual tension. Menopausal symptoms, post-menopausal bleeding. Vaginal discharge, itching, sores, lumps, sexually transmitted infection, and treatments. Sexual interest, satisfaction, any problems, including pain during intercourse (dyspareunia)

-Musculoskeletal  Muscle or joint pain, stiffness, arthritis, gout, backache. If present, describe the location of affected joints or muscles, any swelling, redness, pain , tenderness, stiffness, weakness, or limitation of motion or activity; include timing of symptoms (e.g., morning or evening), duration, and any history of trauma. Neck or low back pain. Joint pain with systemic symptoms such as fever, chills, rash, anorexia, weight loss, or weakness. 

-Psychiatric   Nervousness, tension, mood, including depression, memory change, suicidal ideation, suicide plans or attempts. 

-Neurologic  Changes in mood, attention, or speech;  changes in orientation, memory, insight, or judgment; headache, dizziness, vertigo, fainting, blackouts; weakness, paralysis, numbness, loss of sensation, tingling or “pins and needles,” tremors or other involuntary movement seizures. 

-Hematologic  Anemia, easy bruising, or bleeding

-Endocrine  Heat or cold intolerance, excessive sweating ,excessive thirst (polydipsia), hunger (polyphagia), or urine output (polyuria).

-Physical Examination  

General Survey:  MN is a short, overweight middle-aged female, who is animated and responds quickly  to questions. Her hair was well groomed. Her color is good, and she lies flat.

Vital Signs:  Ht(without shoes) 157 cm (5’2”). Wt (dressed) 65 kg (143 lbs) . BMI 26, BP 164/98 right arm supine; 160/96 left arm, supine; 152/88 right arm, supine with wide cuff. Heart rate (HR) 88 and regular. Respiratory rate (RR) 18. Temperature (oral) 98.6F.

Skin:   Palms cold and moist, but color good. Scattered Cherry angiomas over upper trunk. Nails without clubbing , cyanosis. 

Head, Eyes, Ears, Nose, Throat (HEENT): Head; hair of average texture, Scalp without lesions, normocephalic/ atraumatic (NC?AT). Eyes; Vision 20/30 in each eye. 

Visual fields full by confrontation. Conjunctive pink; sclera white. Pupils 4 mm constricting to 2 mm, round, regular, equally reactive to light. Extraocular movements intact. Disc margins sharp, without hemorrhage, exudate. No arteriolar narrowing or A-V nicking. Ears:  Cerumen partially obscures right tympanic membrane (™); Left canal clear, ™ with good cone of light. Acuity is a good to whispered voice. Weber midline. AC>BC. Nose  Mucosa pink, septum midline. No sinus tenderness. Mouth:  Oral mucosa pink. Dentition is good. Tongue midline. Tonsils absent. Pharynx without exudates. 

Neck:  Neck Supple. Trachea midline. Thyroid isthmus barely palpable, lobes not felt.

Lymph Nodes:  No cervical, axillary, or epitrochlear nodes. 

Thorax and Lungs:   Thorax Symmetric with good excursion. Lungs resonant on percussion. Breath sounds vesicular with no added sounds. Diaphragms descend 4 cm bilaterally.

Cardiovascular:  Jugular venous pressure 1 cm above the sternal angle, with the head of the examining table raised to 30 degrees. Carotid upstrokes brisk, without bruits. Apical impulse discrete and tapping, barely palpable in the 5th left interspace, 8 cm lateral to the midsternal line. Good S1,,.S2,: no S3 or S3,. A II/VI medium-pitched midsystolic murmur at the 2nd right interspace; does not radiate to the neck. No diastolic murmurs. 

Breast:   pendulous, symmetric.. No masses; nipples without discharge. 

Abdomen: Protuberant. Well-healed scar, right lower quadrant. Bowel sounds active. No tenderness or masses. Liver span 7cm  in right midclavicular line; edge smooth, palpable 1 cm below right costal margin (RCM). Spleen not felt. No costovertebral angles tenderness (CVAT).

Genitalia:

Female External genitalia without lesions. Mild cystocele at introitus on straining. Vaginal mucosa pink. Cervix pink, parous, and without discharge. Uterus anterior, midline, smooth, not enlarged . Adnexa is not palpated due to obesity and poor relaxation. No cervical or Adnexal tenderness. Pap Smear taken. Rectovaginal wall intact. 

Male External genitalia without discharge or lesions. No scrotal or testicular mases or swelling, no hernia.

Rectal: No external hemorrhoids, tight sphincter tone, rectal vault without masses, stool brown negative for occult blood.

Extremities: Bilateral upper extremities warm. Bilateral lower extremities; no edema. Calves supple, symmetric, temperature intact bilaterally with negative Homan's sign.

Peripheral vascular: No varicosities in lower extremities. No stasis pigmentation or ulcers Pulses. (2+ = normal)

_________________________________________________________        

Radial           Femoral      Popliteal       Dorsalis Pedis    Posterior Tibial

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Rt 2+ 2+ 2+ 2+ 2+

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Lt 2+ 2+ 2+ 2+ 2+

Musculoskeletal:   No joint deformities or selling on inspection and palpation. Good range of motion in hands, wrists, elbows, shoulders, spine, hips, knees, ankles. 

Neurologic: Mental Status:  Alert and cooperative. Thought processes are coherent and insight is good. Oriented to person, place, and time. Cranial nerves: II to XII intact. Motor: Good muscle bulk and tone. Strength: 5/5 bilaterally in deltoids, biceps, triceps, hand grips, iliopsoas, hamstrings, quadriceps, tibialis anterior, and gastrocnemius. Cerebellar: Rapid Alternating movements (RAMs)  and point-to-point movements intact. Gait stable, fluid. Sensory:  Pinprick, light touch, position sense, vibration, and stereognosis intact. Romberg negative. Reflexes: Bilateral triceps, brachioradialis, patellar and Achilles deep tendon reflexes intact. Bilateral plantar reflex intact. Babinski response is negative.