L. Albert, a 25- year-old college student, is in your clinic because of sore throat. 7 days ago, he developed fever which was low (99 F) to moderate grade (101.1 F). This was associated with swollen and tender neck glands. He has sore throat but denies having cough. He has no abdominal pain but feels as if his upper abdomen has become swollen and he has lost his appetite. He has no nausea, vomiting or change in bowel movements. Since yesterday, he has noticed that his eyes and skin have turned a yellow color. He has no past medical history of jaundice, hepatitis, blood transfusion, body piercing, tattoos or eating shellfish. He does not drink, smoke cigarettes, or use illicit drugs. He doesn’t take any medications. He hasn’t traveled recently. He is sexually active and is in a monogamous relationship with his girlfriend of 2 years who is experiencing similar symptoms. He is heterosexual and has had two previous sexual partners. He always used condoms. He received Hepatitis B vaccination prior to starting college.

PPE: Patient is well-developed, in no acute distress. He appears concerned and anxious.

VS: BP – 130/80, PR- 110/min, RR – 20/min, T – 101.4 F, SpO2 – 99%.

HEENT: PERRLA, EOMI, icteric sclerae, pink conjunctivae, Tonsillo-pharyngeal area erythematous with exudate.

Neck: posterior cervical lymph nodes swollen, tender and movable, bilaterally. Supraclavicular lymph nodes not enlarged. Heart and lungs:

Normal abdomen: Normal bowel sounds, liver – 14 cm in midclavicular line by percussion, diffuse tenderness over both right and left upper quadrants on palpation. Neurological exam: no deficits.

Rubrics…

GUIDELINES FOR INDIVIDUAL CASE STUDY

 

Required elements of the case study:

All papers are to be type written, double spaced, with pages numbered. Please write course name and number, your name, and date clearly on materials submitted. Use American Psychological Association (APA) style 6th edition including paper format and references. Points may be deducted for multiple spelling, grammar, format and typing errors.

 

  1. Subjective (0.5 pt)

State the patient’s chief complaint, reason for visit and/or the problem for which the patient sought consultation.

  1. All symptoms related to the problem are described using the following cue descriptive categories:

1)         Precipitating/alleviating factors (including prescribed and/or self-remedies and their effect on the problem).

2)         Associated symptoms

3)         Quality of all reported symptoms including the effect on the patient’s lifestyle

4)         Temporal factors (date of onset, frequency, duration, sequence of events)

5)         Location (localized or generalized? does it radiate?)

6)         Sequelae (complications, impact on patient and/or significant other)

7)         Severity of the symptoms

  1. Past Medical History including immunizations, allergies, accidents, illnesses, operations, hospitalizations.
  2. Family History includes family members’ health history.
  3. Social history to include habits, residence, financial situation, outside assistance, family inter-relationships.
  4. Review of Systems relevant to the chief complaint/presenting problem is included. Include pertinent positives and negatives.

 

 

  1. 2. Objective (0.5 pt)
  2. Using inspection, palpation, percussion, and auscultation, the examiner evaluates all systems associated with the subjective complaint including all systems which may be causing the problem or which will manifest or may potentially manifest complications and records positive and pertinent negative findings
  3. Performs appropriate diagnostic studies if equipment is available
  4. Records results of pertinent, previously obtained diagnostic studies.
  5. Use Handout Guidelines to Physical Examination.

 

 

  1. Assessment(1.5 pts))
  2. Diagnosis/es is (are) derived from the subjective and objective data
  3. Differential diagnoses are prioritized
  4. Diagnosis/es come(s) from the medical and/or nursing domain
  5. Assessment includes health risks/needs assessment

 

  1. 4. Plan (1.5 pts)
  2. Appropriate diagnostic studies with rationale
  3. Therapeutic treatment plan with rationale
  4. Was this patient appropriate for a nurse practitioner as a provider? Is consultation or collaboration with another health care provider required?
  5. Health promotion/disease prevention carried out or planned: education, discussion, handouts given, evidence of patient’s understanding.
  6. What community resources are available in the provision of care for this client?
  7. Referrals initiated (including to whom the patient is referred to and the purpose)
  8. Target dates for re-evaluating the results of the plan and follow up

 

  1. Other (1 pt)
  2. Information is typed, double-spaced, 12pt font, and concise (using short paragraphs and phrases)
  3. Information is written so that the objective reader can follow the progression of events and information
  4. Only standard, accepted medical terminology and abbreviations are used.
  5. At least three (3) references from recent professional journal publications are required for each (APA format). These can include but not limited to medical, research, pharmacological or advanced practice nursing journals.  More than 3 references should be used.
  6. Rationales need to include a clear demonstration of the use of evidence-based practice in decision-making. Risks and benefits as well as how an intervention was determined to be evidence-based will be clear to the reader.

 

  1. Rationales need to include a clear demonstration of the use of evidence-based practice in decision-making. Risks and benefits as well as how an intervention was determined to be evidence-based will be clear to the reader.

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L. Albert, a 25- year-old college student, is in your clinic because of sore throat. 7 days ago, he developed fever which was low (99 F) to moderate grade (101.1 F). This was associated with swollen and tender neck glands. He has sore throat but denies having cough. He has no abdominal pain but feels as if his upper abdomen has become swollen and he has lost his appetite. He has no nausea, vomiting or change in bowel movements. Since yesterday, he has noticed that his eyes and skin have turned a yellow color. He has no past medical history of jaundice, hepatitis, blood transfusion, body piercing, tattoos or eating shellfish. He does not drink, smoke cigarettes, or use illicit drugs. He doesn’t take any medications. He hasn’t traveled recently. He is sexually active and is in a monogamous relationship with his girlfriend of 2 years who is experiencing similar symptoms. He is heterosexual and has had two previous sexual partners. He always used condoms. He received Hepatitis B vaccination prior to starting college.

PPE: Patient is well-developed, in no acute distress. He appears concerned and anxious.

VS: BP – 130/80, PR- 110/min, RR – 20/min, T – 101.4 F, SpO2 – 99%.

HEENT: PERRLA, EOMI, icteric sclerae, pink conjunctivae, Tonsillo-pharyngeal area erythematous with exudate.

Neck: posterior cervical lymph nodes swollen, tender and movable, bilaterally. Supraclavicular lymph nodes not enlarged. Heart and lungs:

Normal abdomen: Normal bowel sounds, liver – 14 cm in midclavicular line by percussion, diffuse tenderness over both right and left upper quadrants on palpation. Neurological exam: no deficits.

Rubrics…

GUIDELINES FOR INDIVIDUAL CASE STUDY

 

Required elements of the case study:

All papers are to be type written, double spaced, with pages numbered. Please write course name and number, your name, and date clearly on materials submitted. Use American Psychological Association (APA) style 6th edition including paper format and references. Points may be deducted for multiple spelling, grammar, format and typing errors.

 

  1. Subjective (0.5 pt)

State the patient’s chief complaint, reason for visit and/or the problem for which the patient sought consultation.

  1. All symptoms related to the problem are described using the following cue descriptive categories:

1)         Precipitating/alleviating factors (including prescribed and/or self-remedies and their effect on the problem).

2)         Associated symptoms

3)         Quality of all reported symptoms including the effect on the patient’s lifestyle

4)         Temporal factors (date of onset, frequency, duration, sequence of events)

5)         Location (localized or generalized? does it radiate?)

6)         Sequelae (complications, impact on patient and/or significant other)

7)         Severity of the symptoms

  1. Past Medical History including immunizations, allergies, accidents, illnesses, operations, hospitalizations.
  2. Family History includes family members’ health history.
  3. Social history to include habits, residence, financial situation, outside assistance, family inter-relationships.
  4. Review of Systems relevant to the chief complaint/presenting problem is included. Include pertinent positives and negatives.

 

 

  1. 2. Objective (0.5 pt)
  2. Using inspection, palpation, percussion, and auscultation, the examiner evaluates all systems associated with the subjective complaint including all systems which may be causing the problem or which will manifest or may potentially manifest complications and records positive and pertinent negative findings
  3. Performs appropriate diagnostic studies if equipment is available
  4. Records results of pertinent, previously obtained diagnostic studies.
  5. Use Handout Guidelines to Physical Examination.

 

 

  1. Assessment(1.5 pts))
  2. Diagnosis/es is (are) derived from the subjective and objective data
  3. Differential diagnoses are prioritized
  4. Diagnosis/es come(s) from the medical and/or nursing domain
  5. Assessment includes health risks/needs assessment

 

  1. 4. Plan (1.5 pts)
  2. Appropriate diagnostic studies with rationale
  3. Therapeutic treatment plan with rationale
  4. Was this patient appropriate for a nurse practitioner as a provider? Is consultation or collaboration with another health care provider required?
  5. Health promotion/disease prevention carried out or planned: education, discussion, handouts given, evidence of patient’s understanding.
  6. What community resources are available in the provision of care for this client?
  7. Referrals initiated (including to whom the patient is referred to and the purpose)
  8. Target dates for re-evaluating the results of the plan and follow up

 

  1. Other (1 pt)
  2. Information is typed, double-spaced, 12pt font, and concise (using short paragraphs and phrases)
  3. Information is written so that the objective reader can follow the progression of events and information
  4. Only standard, accepted medical terminology and abbreviations are used.
  5. At least three (3) references from recent professional journal publications are required for each (APA format). These can include but not limited to medical, research, pharmacological or advanced practice nursing journals.  More than 3 references should be used.
  6. Rationales need to include a clear demonstration of the use of evidence-based practice in decision-making. Risks and benefits as well as how an intervention was determined to be evidence-based will be clear to the reader.

 

  1. Rationales need to include a clear demonstration of the use of evidence-based practice in decision-making. Risks and benefits as well as how an intervention was determined to be evidence-based will be clear to the reader.

Leave a Reply

Your email address will not be published. Required fields are marked *