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Wk 6 case study jessica edit - Guide to NR511 Case Studies (Sep2018).
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Wk 6 case study jessica edit - Guide to NR511 Case Studies (Sep2018).
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Part 11. 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. A brief AND
concise summary of the history and physical (H&P) findings is presented
without redundancy or irrelevant information
In Part 1, you are given a patient scenario. Using the information given, answer the
following questions:
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.
Do NOT simply rewrite the information as is it is presented in the case. This is NOT
a SOAP note. The information that you present to your preceptor should include
only what is needed. State the chief complaint (CC), HPI, and relevant history and
physical findings. You can use shorthand and medical abbreviations. Don’t be
redundant.
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].
,2. Provide a differential diagnosis (minimum of 3) which might explain
the patient's chief complaint along with a brief statement of
pathophysiology for each. Three (3) appropriate diagnoses in the
differential are presented which can explain the patient’s chief complaint
AND A brief statement of pathophysiology is included for each diagnosis
Provide a differential diagnosis (minimum of 3) which might explain the patient’s
chief complaint along with a brief statement of pathophysiology for each.
The pathophysiology statement does not need to be extensive but it should not be
vague either. Just list the diagnosis and follow with a pathophysiology statement for
each diagnosis.
Example:
Diagnosis #1
-Pathophysiology statement
3. Analyze the differential by using the pertinent findings from the
history and physical to argue for or against a diagnosis. Each diagnosis
in the differential is analyzed using pertinent positive and negative
subjective and objective findings as support; AND
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).
This is where you present your argument for EACH DIAGNOSIS individually using the
patient’s pertinent subjective and objective information from the scenario.
Example:
Diagnosis # 1-Streptococcal pharyngitis
, Strep pharyngitis is at the top of my differential. A streptococcal bacterial infection
should be ruled out in a patient presenting with pharyngitis to prevent serious
complications such as rheumatic fever.
• Pertinent positive findings:
ST, fever, nausea, lymph node swelling, bad breath {subjective findings};
posterior pharynx erythema, 3+ tonsillar edema, tonsillar exudate, halitosis,
anterior cervical chain lymphadenopathy and tenderness, T 101.5 {objective
findings}
• Pertinent negative findings:
No known recent exposure to person with strep, no rash, no cough
4. Rank the differential in order of most likely to least likely. The
differential is ranked in order from most likely to least likely
5. 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. Clinical reasoning skills are demonstrated by linking testing to
diagnoses as applicable; AND Testing decisions are well supported with EBM
arguments that are in-line with the clinical scenario and appropriate for the
primary care setting
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.
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