case studies

case studies.

NU610 Unit 3 Case Studies

 

Review the following case studies.

Document the subjective information only for each case in a Word document and submit it to Canvas.  This will be evaluated by the clinical faculty. 

 

 

Case 1

A 36-year-old female with a medical history of Multiple Sclerosis complains of constantly feeling tired even after a period of rest or sleep. She was diagnosed with MS 3 years ago and has been taking interferon to treat. As a wife and mother of 2 with a full-time job, she states that by the end of the day she has no energy whatsoever. The patient explains that she began noticing her lack of energy and tiredness a few months back, but it has gotten progressively worse. She also mentions that she has missed several days at work over the last 4 weeks because after getting showered and dressed, she had no energy left to go to work.  Reports occasional glass of wine on the weekends, denies tobacco use or illicit drug use.  She has tried some CBD oil to help with energy without relief.  Reports sleeping more than eight hours a night while needing several naps throughout the day.  She reports uncomfortable buzzing sensation traveling from neck down to spine with what sounds to be a Lhermitte’s sign.  She denies loss of bowel or bladder.  She denies fever, chills, weight loss or weight gain.  She reports some nasal congestion but contributes that to allergies which she takes cetirizine 10 mg PO daily for.  Reports she up to date on her pap smear, does monthly self-breast exam, denies concerns on exam.  Saw her dentist and eye doctor within the last year and no issues or concerns there.  Reports her mother who is alive has diabetes and hypertension.  Her father and siblings are also alive without any health issues.  She does have an aunt on her mother’s side who had MS as well who is currently wheelchair bound.  She is alert, oriented to person, place, time and situation. Does not appear in acute distress, well-developed, slightly obese in the abdominal section.  Skin is dry, warm, and intact.  Normocephalic, neck supple, no thyromegaly.  PERRLA about 4mm pupil size.  Conjunctivae rim pale. Optic fundi examined revealed uniform red to pink color, disk is pale pink, vessels emanate from optic cup, fovea was slightly darker.  Retinal vessels are free from hemorrhages or exudates.  Face symmetrical.  No lymphadenopathy.  Oral mucosa pink and moist.  Heart rate bradycardic at 56 beats per minute but regular without pauses or extra beats.  Lungs diminished bilaterally but otherwise clear.  Abdomen soft, non-distended, bowel sounds normoactive in all four quadrants.  No suprapubic or CVA tenderness.   Able to differentiate between light and deep tough, no dysmetria or ataxia, normal alternating hand movements, gait steady.  Muscle tone inspected and palpated, free from fasciculation, tenderness or atrophy.  Strength 5/5 in all extremities.

 

 

 

Case 2

A 35-year-old male presents with the onset of acute low back pain.  He was doing some yard work, including pulling out large bushes, when he experienced the acute onset of low back pain, radiating down the back of the left leg. Since then, the pain has worsened in intensity, and he is having difficulty bearing weight on the leg. He initially took 800 mg ibuprofen, which provided a small degree of relief, but he has not taken any medication since the problem initially occurred. The patient has no significant medical history. His general physical examination is within normal limits with regards to cardiovascular and pulmonary system.  On neurological examination, he has severe pain with active movement of the lower extremity, but only minimal pain with passive movement of the lower extremity. He has a positive straight leg raise but no other neurological deficits.  Denies loss of bowel or bladder or saddle anesthesia.  Denies fever, chills, weight loss or weight gain.  Denies headaches, dizziness, rashes or bruising.  Denies history of lower back pain or previous injury to back.  He is recently divorce and shares custody of three children.  He reports smoking about 1 pack of cigarettes a day for 10 years but quit 5 years ago, currently vapes daily.  He reports one beer with dinner, denies illicit drug use. Denies hospitalizations or surgical history.  He does not get regular health maintenance and only sees primary care provider when has acute issue.  He works for IT department from home and sits about 8 hours per day.  He reports running at least 30 minutes daily and overall eats “healthy.”  Denies family history of spine or musculoskeletal diseases or malignancy.  VS in office BP 124/78, HR 79, RR 16, Temp 97.3, 100% on RA.  Appears in acute distress related to pain.  Rates pain 8 out of 10, described as sharp, lightening sensation. 

 

Case 3

An 83-year-old female presents to the clinical with a productive cough for the last 3 weeks. She notices that she has had a fever off and on over that time with highest temperature of 100.3.  She coughs so much that she has chest pain which is worse at night. She reports having a mild sore throat and nasal congestion.  She tried taking guaifenesin without relief. She has no history of asthma or any chronic lung diseases. Past medical history includes osteoarthritis which she takes Tylenol 500 mg PO daily; depression which she takes citalopram 10 mg PO daily; GERD which she takes omeprazole 10 mg PO daily; and hypothyroidism which she takes levothyroxine 88 mcg PO daily as soon as she wakes every morning.  Allergy to PCN with reaction of hives.  Hospitalized for birth of three children and right knee replacement 2 years ago.  She lives in a retirement community, uses rolling walker for long distance walking and cane for around the house.  Her children live close by and help her with errands.  All her children are alive and well, no one with similar symptoms.  She reports being up to date on vaccines including flu and pneumonia vaccine.  She wears her mask when she goes out in public and maintains a physical distance of six feet while practicing good hand hygiene. She denies nausea, vomiting diarrhea and recent travel. She denies smoking, alcohol, or illicit drug use. Upon examination temperature is 98.6, pulse 96, blood pressure 124/82 and respirations are 18. O2 sat is 99% on room air.  Wt.: 235 lbs., Ht. 63 inches and BMI 41.62. She does not appear in acute distress or acutely ill.  Alert and oriented x 4.  Pupils are equal, round, reactive to light, no nystagmus or strabismus.  Mucous membranes moist.  No tonsillar exudate, oropharynx clear.  Nares patent with clear drainage.  TM gray color with cone of light present bilaterally. Neck examination is negative for JVD, bruits, adenopathy or masses. Chest examination reveals symmetrical chest motion with occasional wheezes but normal air movement. Heart irregular rate and rhythm with grade 2 systolic murmur heard greatest over the right sternal border. Capillary refill less than 3 seconds.  Bowel sounds present in all four quadrants with soft, non-distended and non-tender abdomen.  Peripheral pedal pulses +2 bilaterally without edema.

 

Case 4

A 64-year-old presents for a routine evaluation. The patient only complaint is of fatigue over the past 2 to 3 months although has had no changes in diet or lifestyle.  Consumes about 3 cups of coffee per day. The patient does report that they never smoked and admits to an “occasional beer with friends”. The patient has consumed a little more since retiring a year ago from the post office and admits to 2-3 now a day. The patient occasionally has headaches on the day after a night of heavier drinking. The headaches are relieved by over the counter non-steroidal anti-inflammatory medication (NSAID). While talking to the patient you notice no distress you note a 4-pound weight loss since his last visit 6 months ago and an increase in pulse at 103 BPM but regular with a blood pressure of 129/81. No history of allergies. Reports family history of diabetes, hypertension, cardiac disease and colon cancer.  Upon exam you notice paleness of conjunctivae and palmar pallor.  Abdomen round with distention, bowel sounds hyperactive in two of the four quadrants.  No suprapubic or CVA tenderness.  No lymphadenopathy or swelling.  You perform a digital rectal exam and find a smooth normal size prostate and some soft, reducible protrusions within the internal sphincter along with guaiac positive stools.  Denies any past medical history, surgical history or hospitalizations.  Reports fatigue but denies fever or chills.  Denies changes in visual or trouble swallowing.  Denies chest pain, palpitations, lightheadedness or sweating.  Denies nausea, vomiting, abdominal pain.  Has a bowel movement daily which recently has been dark in color.  Denies urinary frequency, burning or hematuria.  Denies cold or heat intolerance. 

 

Case 5

A 19-year-old female presents with a complaint of headaches frequently. She reports that she has had them since she was a teenager, but they have become more debilitating recently. The episodes occur once or twice a month and last for up to 2 days. The pain begins in the right temple or the back of the right eye and spreads to the entire scalp over a few hours. She describes the pain as a sharp, throbbing sensation that gradually worsens and is associated with sever nausea. Several factors aggravate the pain including loud noises and movement. She has taken several over the counter medication like naproxen and acetaminophen for the pain but the only thing that makes it better is going to sleep in a dark quiet room. Reports no drug allergies but has seasonal and allergies to pet dander.  A thorough history reveals her mother suffers from migraines. Last menses 4 weeks ago, is sexually active uses condoms.  Currently a freshman in college.  Denies alcohol, illicit drug and tobacco use.  Last health visit was over the Summer, up to date on health maintenance for her age.  She denies fever, chills, night sweats or neck stiffness.  She denies visual changes other than photophobia.  She denies chest pain, palpitations, shortness of breath or cough.  She denies abdominal pain, has some nausea with the headaches but no vomiting.  Denies numbness, tingling, weakness or changes in mood.  Vital signs: temperature 98.5, BP 112/70, HR 62, RR 17, 99% RA, Ht. 68 inches, Wt. 151 lbs.  Alert and oriented to self, place, time and situation.  Appears stated age with skin warm and dry.  Normocephalic, PERRL, TM gray with adequate conf of light bilaterally, no tenderness over sinuses.  Mucous membranes pink and dry.  No palpable masses, adenopathy or thyroid enlargement.  Regular heart rate and rhythm without murmurs. No edema.  Lungs clear bilaterally, no use of accessory muscles.  Soft, non-tender, non-distended abdomen with normoactive bowel sounds.  Normal visual acuity using Snellen chart 20/20, face symmetrical with symmetrical smile and puffing out cheeks.  Weber and rhinne test performed with normal bone and air conduction.  Palate and uvula at rest are free of fasciculations and symmetry noted at test and when pt. says “ah.” Positive gag reflex.  Shrug shoulders spontaneously and against resistance, hypoglossal nerve intact. Muscle tone inspected, palpated without atrophy and strength 5/5.  Bicep, patellar and Achilles reflexes 2+ bilaterally with negative Babinski.  Able to distinguish light and deep touch.  Able to complete heel to shin, gait steady. 

stimated time to complete: 1 hour

Rubric

NU610 Unit 3 Assignment – Case Studies Rubric

NU610 Unit 3 Assignment – Case Studies Rubric

Criteria

Ratings

Pts

This criterion is linked to a Learning OutcomeSubjective Data

40 pts

Highly Proficient

Elements of subjective data (CC, HPI, PMH, Allergy identification, Medication Reconciliation, Social History, Family History, Health Promotion, and ROS) are adeptly documented and demonstrate consistent information across all aspects represented

32 pts

Proficient

Elements of subjective data (CC, HPI, PMH, Allergy identification, Medication Reconciliation, Social History, Family History, Health Promotion, and ROS) are appropriately documented and demonstrate consistent information across all aspects represented

24 pts

Marginally Proficient

Elements of subjective data (CC, HPI, PMH, Allergy identification, Medication Reconciliation, Social History, Family History, Health Promotion, and ROS) are satisfactorily documented but do not demonstrate consistent information across all aspects represented

16 pts

Approaching Proficiency

Elements of subjective data (CC, HPI, PMH, Allergy identification, Medication Reconciliation, Social History, Family History, Health Promotion, and ROS) are either not satisfactorily documented or do not demonstrate consistent information across all aspects represented

8 pts

Not Proficient

Elements of subjective data (CC, HPI, PMH, Allergy identification, Medication Reconciliation, Social History, Family History, Health Promotion, and ROS) are not satisfactorily documented and do not demonstrate consistent information across all aspects represented

0 pts

Not Evident

There are elements of subjective data (CC, HPI, PMH, Allergy identification, Medication Reconciliation, Social History, Family History, Health Promotion, and ROS) that are not provided in assignment.

40 pts

Total Points: 40

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case studies