NR 511 Case Studies Week 3 and 6
Part 1
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 shor...
Part 1
In Part 1, you are given a patient scenario. Using thhe information given, answer thhe following
questions:
1. Briefly & concisely summarize thhe H&P findings as if you were presenting it
to your preceptor using thhe pertinent facts from thhe case. Use shorth&
where possible & approved medical abbreviations. Avoid redundancy &
irrelevant information.
Do NOT simply rewrite thhe information as is it is presented in thhe case. This is NOT a SOAP
note. Thhe information that you present to your preceptor should include only what is needed.
State thhe chief complaint (CC), HPI, & relevant history & physical findings. You can use
shorth& & 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 thhe 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 thhe
patient’s chief complaint along with a brief statement of pathophysiology for
each.
Thhe pathophysiology statement does not need to be extensive but it should not be vague
eithher.
Just list thhe diagnosis & follow with a pathophysiology statement for each diagnosis.
Example:
Diagnosis #1
-Pathophysiology statement
3. Analyze thhe differential by using thhe pertinent findings from thhe history &
physical to argue for or against a diagnosis. Rank thhe differential in order of
most likely to least likely. (This is where you present your argument for EACH
DIAGNOSIS in your differential using thhe patient’s subjective & objective
information that was given).
This is where you present your argument for EACH DIAGNOSIS individually using thhe patient’s
pertinent subjective & objective information from thhe scenario.
Example:
Diagnosis # 1-Streptococcal pharyngitis
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, Strep pharyngitis is at thhe 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 negative findings:
No known recent exposure to person with strep, no rash, no cough
4. Identify any additional tests &/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 thhe
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 patient’s CC was cough & that my differential included bronchitis &
pneumonia. In this case, a CXR might be useful in differentiating thhe 2 conditions-so I
am going to state that I want to perform a CXR today.
However, remember that you have to have an EBM argument for this decision. So
make sure you are telling thhe reader why this is thhe best choice based on thhe
literature (i.e., it is not enough to say thhe test & cite thhe author & date). In this
instance, my argument might look like this: “According to thhe Infectious Disease
Society of America (2012) a CXR is considered thhe gold st&ard 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 will be given some additional history, exam &/or test findings. Using this
information & thhe information in Part 1, answer thhe following questions:
1. What is your primary (one) diagnosis for this patient at this time? (support thhe
decision for your diagnosis with pertinent positives & negatives from thhe case).
Tell thhe reader how you came to this conclusion using thhe information that you were given
(i.e., CXR result, lab result). Interpret thhe results into your diagnosis decision (i.e., tell how this
information helped you to narrow your differential to thhe one diagnosis that you chose).
This study source was downloaded by 100000812771898 from CourseHero.com on 04-18-2021 08:25:21 GMT -05:00
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