CASE STUDY Custom Essay

Midterm Assignment

For each of the cases presented provide the following information:

1. What additional health history information would you like to gather and why would you ask? Be specific, succinct & clear. (You must document a minimum of 5 items each with a rationale.)

2. In addition to the general survey and vital signs, what other components of the PE do you need to complete? (Select at least 3 additional systems and indicate what information you hope to gather from that portion of your physical exam and why you would choose to assess that specific system.)
� General Survey (must include, state what you are looking for)
� Vital Signs (must include, state what the various values may indicate)
� Skin
� Neck
� Lungs
� Cardiovascular
� Abdomen
� Peripheral Vascular/Extremities
� Musculoskeletal
� Neurological System

3. Based on the limited data you have collected, what are your 3 prioritized differential diagnoses, with rationale, for the patient?

Note: See Grading Criteria and Instructions for this assignment posted on BlackBoard.

CC: �I have a mole on my back.�
Demographics & partial HPI: Gloria is a 22 year old female who presents to the clinic for evaluation of a �dark� mole she has on her back. She reports that she has just returned from a remote, tropical South Seas island where she was a contestant on the television show Survivor: Phillipines. Prior to leaving, she was required to have a complete physical done and was told that she was in �perfect health�. She denies any pain, itching, or tenderness to the site of the mole. She is an established patient in your clinic and has no pre-existing health issues and no prior surgeries. She has no other complaints.
CC: �I have a sore throat.�
Demographics & partial HPI: Mary M. is a 15 year old female high school student who presents to your clinic accompanied by her mother. She is an established patient in your clinic and has no pre-existing health issues and no prior surgeries. Her mother states that she started complaining of a sore throat about 4 days ago, but thought it was due to her seasonal allergies. She treated her daughter�s symptoms with acetaminophen, and diphenhydramine (Benadryl). Mary�s mom decided to bring her daughter to the clinic because �she doesn�t seem to be getting any better.�
CC: �I have been having this nagging cough.�
Demographics & HPI: Mr. Jack B. is a 62 yr old male retired lawyer who presents to your clinic as a new patient. He states that he has had several episodes of coughing off and on for the past few months and since �it always seems to go away�, he wasn�t too worried. He is here because his wife insisted that he should be seen and evaluated. He reports he is in good health and has an �active lifestyle traveling with his wife and playing golf at least twice a week.� He takes medication for high blood pressure, a baby aspirin daily, and one multivitamin per day.
CC: �My son has a rash all over.�
Demographics & partial HPI: Mrs. C. presents to the clinic with her 3 year old son Joshua complaining of a rash that began yesterday evening. She reports that Joshua has been suffering from �cold and fever� for the past 5 days but is worried because now he has developed a rash. She states the child has no medical problems and has never had any surgeries. No one else is sick at home.

The purpose of this mid-term assignment is to assess your ability to analyze a set amount of data, think critically, and formulate potential differential diagnoses that will support you in providing care for your patients.

After reading the brief patient scenario (case study), you should ask, �What else do I need to know and why do I need to know it?�

For example, in Part 1 of each case study, you are asked to determine what additional health history questions should be asked as it relates to the patient�s chief complaint (e.g. �I feel so queasy. I can�t keep anything down�.) Your response may be something as simple as �when did you first feel nauseous?� You may also ask about associated signs or symptoms, but you must be specific and provide rationale. You then need to consider why you want to ask these specific questions. Once again, your answer should be clear and succinct with rationale. In this example, you would want to know when the patient first became nauseous because it may relate to something they ate. Or, if the patient is female and sexually active, you may need to ask questions related to the possibility of pregnancy. This subjective information will help you determine appropriate differential diagnoses.

In Part 2, you are asked to identify what components of the physical exam should be assessed. Again, you need to be specific and provide the rationale for why you want to assess that component, or gather that information � e.g. if pt has a cardiac complaint and you indicate you would listen to heart sounds, what are you specifically listening to or for? S3, S4, murmurs? Why are you listening, what would these sounds indicate?

Finally, in Part 3, you are to list three prioritized differential diagnosis based on the limited information you have been given. Think critically � there is a wide variety of possible explanations for each scenario however, you must be able to support your answer with a logical and evidenced-based rationalization for each of your differentials.

The document with the 4 case studies will be posted on Blackboard. You do not have to include the whole case studies in your document just the case study number and a brief description of the case. Your answers may be single spaced however the cover page and references cited within the document and the reference page(s) must be in APA format (6th Edition).

Please place your completed assignment in the Black Board drop-box under �Midterm Assignments� before 11:00 PM on the due date. Late assignments will not be accepted without prior approval and only under extreme circumstances. Good luck!!
NURS 6210 � Mid-Term Grading Rubric
Student:________________ Date:______
Grading Criteria Possible Points Earned Points & Faculty Comments
Case Study #1
Health Hx w/rationales 10
Physical Exam w/rationales 10
Prioritized Differential Dx 2.5

Case Study #2
Health Hx w/rationales 10
Physical Exam w/rationales 10
Prioritized Differential Dx 2.5

Case Study #3
Health Hx w/rationales 10
Physical Exam w/rationales 10
Prioritized Differential Dx 2.5

Case Study #4
Health Hx w/rationales 10
Physical Exam w/rationales 10
Prioritized Differential Dx 2.5

Organization/Grammar/APA 10



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