Guide to NR511 Case Studies (Week 3 & 6)

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 complaintalong 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 argumentas 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 1^st 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

Week 6: Discussion Part One

A 56-year-old Caucasian female presents to the office today with complaints of fatigue. Upon further questioning you discover the following subjective information regarding the chief complaint.

History of Present Illness
Onset	“about 2-3 months”
Location	Generalized
Duration	Constant
Characteristics	Progressively worsening since onset, feels tired all of the time, sleeps 8hrs per night but does not feel well rested. “No energy to do anything I normally can do”
Aggravating factors	Exertion
Relieving factors	None identified
Treatments	None
Severity	Denies pain; missed 1 day of work 2 weeks ago because “couldn’t get out of bed”
Review of Systems (ROS)
Constitutional	Denies fever, chills, or recent illnesses. +5lb. weight gain since last visit 6 months ago.
Eyes	No visual changes or diploplia
ENT	Denies ear pain, coryza, rhinorrhea, or ST. Had tonsillectomy as child Denies snoring or history of sleep apnea.
Neck	Denies lymph node tenderness or swelling
Chest	Denies cough, SOB, DOE or wheezing
Heart	Denies chest pain
Abdomen	Denies N/V/D. + Constipation
Endocrine	Denies polyuria, polydipsia. + cold intolerance. Menopause status x 5 yrs.
Skin	No changes in skin, hair or nails
Psych	Reports worsening of depressive symptoms but thinks it is because she is so “unproductive” lately and tired all of the time. -Suicidal or homicidal thoughts. Sleeping 8-9hrs per night (no changes), but not feeling rested.
Musculoskeletal	Generalized weakness and intermittent muscles cramping in calves

History
Medications	Multivitamin, B-Complex, Prozac 20mg, Bisoprolol-HCTZ 2.5mg/6.25mg, Calcium 500mg + Vit D3 400IU.
PMH	HTN, Depression, Postmenopausal status
PSH	Tonsillectomy
Allergies	Iodine dyes
Social	Married; Works full time as office manager of an internal medicine office; 2 kids (grown)
Habits	Denies cigarettes or drug use. +Occasional glass of wine (1-2 per month).
FH	Maternal GM & GF deceased with CHF, T2DM and HTN; Mother alive (age 82) +HTN, +Hyperlipidemia, +T2DM; Father alive (age 84) +HTN, +Hyperlipidemia, +T2DM, +ASHD (s/p CABG 2 years ago). Also had +CVA at time of CABG (work-up revealed +DVT and +PFO; remains anticoagulated); Oldest child (26) with seasonal allergies Youngest child (24) with Bipolar depression and ADHD, and anxiety

Physical exam reveals the following:

Physical Exam
Constitutional	Middle aged Caucasian female alert, oriented and cooperative
VS	Temp-98.2, P-74, R-16, BP 146/95, Height: 5’7″, Weight: 180 pounds
Head	Normocephalic, atraumatic
Eyes	PERRLA
Ears	Tympanic membranes gray and intact with light reflex noted.
Nose	Nares patent. Nasal turbinates without swelling. Nasal drainage is clear.
Throat	Oropharynx moist, no lesions or exudate. Surgically removed tonsils bilaterally. Teeth in good repair, no cavities.
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. No pedal edema
Abdomen	Soft, non-tender. BS active
Skin	Skin overall dry, hair coarse and thick, nails without ridging, pitting or discoloration
Psych	Mood pleasant and appropriate.
Musculoskeletal	Strength full throughout
Neuro	DTRs 2+ at biceps, 1+ at knees and ankles

· 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.

· 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.

Week 6: Discussion Part Two

Now, assume that you sent your patient for labs and she returns the following day, as instructed, to review the results.

CBC with differential

WBC	8.6 x10E3/uL
RBC	4.44 x 10E6/uL
Hemoglobin	14.0 g/dL
Hematocrit	41.2%
MCV	93fL
MCH	31.5 pg
MCHC	34.0 g/dL
RDW	13%
Platelet	241 x 10E3/uL
Neutrophils %	67%
Lymphocytes %	22%
Monocytes %	8%
Eosinophils %	3%
Basophils %	0%
Absolute Neutrophils	5.7 x 10E3/uL
Absolute Lymphocytes	1.9 x 10E3/uL
Absolute Monocytes	0.7 x 10E3/uL
Eosinophils Absolute	0.3 x 10E3/uL
Basophile Absolute	0.0 x 10E3/uL
Immature Grans %	0%
Absolute Immature Grans	0.0 x 10E3/uL

TSH with Reflex to FT4

TSH	6.770 uIU/mL
FT4	0.62 ng/dL

PHQ-9 Depression Score=10 (previous was 5 at last visit 6 months ago)

· What is your primary diagnosis for this patient as the cause for the CC of fatigue? (support your 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.

· Are there any changes that you would make to the patient’s overall plan at this time? Must provide an evidence-based medicine (EBM) argument to support any treatments or testing decisions.

· Provide an appropriate follow-up plan (include any additional testing that you feel is necessary and include an EBM argument).

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

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