08 Jul LIST THE PATIENT’S SIGNS AND SYMPTOMS AND INCLUDE A RATIONALE STATEMENT THAT EXPLAINS HOW THE DIAGNOSIS IS APPROPRIATE FOR YOUR PATIENT.
SUBJECT: Nursing
TYPE: Case Study
PAGES: 5
DESCRIPTION:
Setting: large urban city Family practice clinic which employs physicians and nurse practitioners. Today is another busy in your family practice clinic. You note your next visit is a “2fer”. This means you have two patients to see in this visit. You ask your medical assistant to tell you why they are here. Your medical assistant tells you the patients are daughter and father.
The daughter has burning with urination and the dad came along for the visit because he has some back pain. You review the chart before entering the room to familiarize yourself with these patients. When you enter the room you note a Caucasian woman who appears to be about 40 years old. She is well groomed and appropriately dressed for the weather. She is sitting in the chair. The man is well groomed, appears to be about 70 years old, and is sitting on the exam table leaning forward. You introduce yourself as you always do and ask what brings them to the clinic today. Mary HPI Reports burning with urination and feeling very itchy and uncomfortable in that area. PMH Age 44. No chronic illness or injuries. Recently treated for strep throat with a 10 day course of penicillin. Completed 1 day ago. Hospitalized x 2 for childbirth, no surgeries. NKDA. Drinks alcohol socially, denies tobacco or illicit drug use. Sleeps 6-7 hours/night. No current medications. Takes a daily multivitamin and a B complex vitamin. Social history Mary is married with four children ages 4-9. She works full time.
Mary’s parents Katie and John also live in the home. Both are retired and help with childcare and household needs since both parents work full time. Her husband and father both smoke but not in the house. Family history Mary has 2 siblings who are in good health. Mother has a history of HTN, hyperlipidemia and osteopenia. Father has HTN and hyperlipidemia. They share their home with 2 dogs and a cat. John HPI States he has had some back pain for three days that has not gotten better. He has taken Tylenol three times per day and though it takes the edge off it has not helped much and the pain is still there. PMH Age 75. Has HTN and hyperlipidemia. No previous injuries. No hospitalizations or surgeries. Takes Lipitor 40 mg daily and Lisinopril/HCTZ 20, 12.5 daily.
Allergic to Bactrim. Sleeps 6-7 hours a night. Social Born in Ireland, has lived in America for 45 years. Lives with his wife in his daughter and son in laws home. Retired carpenter. Helps with the kids by taking them to school and after school activities. Enjoys gardening and fixing things around the house. Drinks ETOH on the weekends and smokes 1 pack a day. Denies other drug use. FMH Parents lived until their 80’s. Has 13 siblings, most are alive. One brother died suddenly of a heart attack age 45 and lost a sister at age 4 to consumption. No family health problems except for high blood pressure when they get older. Discussion part one: What further questions do you have for Mary at this visit? Use OLDCARTS to guide your questions. Link the questions to your differential diagnoses.
What is your differential diagnosis list with ICD 10 for this visit thus far? Each differential diagnosis should include a one sentence pathophysiology statement supported by the literature. List the patient’s signs and symptoms and include a rationale statement that explains how the diagnosis is appropriate for your patient. Based on your differential diagnoses list, what focused PE would you perform? What labs or diagnostic tests, if any, would you order? What further questions do you have for John at this visit? Use OLDCARTS to guide your questions.
Link the questions to your differential diagnoses. What is your differential diagnosis list with ICD 10 for this visit thus far? Each differential diagnosis should include a one sentence pathophysiology statement supported by the literature. List the patient’s signs and symptoms and include a rationale statement that explains how the diagnosis is appropriate for your patient. Based on your differential diagnoses list, what focused PE would you perform? What labs or diagnostic tests, if any, would you order?
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