Human Case Reason Explained for Students (Easy Guide)

This type of question evaluates analytical and critical thinking skills.

What This Question Is About

This question relates to human case reason and requires a structured academic response.

How to Approach This Question

Use appropriate theories and support your answer with clear reasoning.

Key Explanation

This topic involves human case reason. A strong answer should include explanation, application, and examples.

Original Question

I-Human case 30 y/o, 5’5 (165 cm), 120.0 lb (54.5 kg), Reason for encounter Neck pain. Location outpatient clinic with x-ray, ECG, and laboratory capabilities, The front of my neck is really sore and I wanted to get it checked out. Well to start I have worked extra hours at work over the last week and so I’ve been using my neck a lot but I don’t wear anything around it. I’m a dental hygienist and always am bending over patients to look into the corners of their mouths. So my neck might have already been a little sore from that. But I also told my husband I wanted to spend a few nights at my parents to take mom to her cardiology appointment. He got so mad, saying I’m spending too much time with them. We argued for a bit and then he just lunged at my neck. He grabbed it with one hand and just held me there for 30 seconds. I could see the wall clock over his shoulder. History of Present Illness The patient is a 30-year-old female who reports that she has neck pain that started gradually after prolonged desk work and worsened following an intimate partner violence (IPV) incident two days ago. During an altercation, she claims to have been physically restrained around the neck for about 30 seconds. Her job as a dental hygienist, which requires prolonged neck flexion, makes the pain, which is localized to the front of the neck and a little on the side worse. Patient describes pain as sore and achy, rated 7/10 on the numeric pain scale which she took over the counter Ibuprofen 200mg Q4 to 6 hours PRN. She reports soreness that gets worse with movement, but she denies having trouble breathing, swallowing, or hoarseness. No associated fever, weakness, or numbness. There are no notable chronic illnesses, past surgical procedures includes; tonsillectomy, at 10 years, wisdom tooth extraction at at 19years, an elective termination at 23 years. No known allergies in her medical history. She experiences social stress at home as a result of IPV, which could exacerbate her symptoms. What assessment questions should an advanced nurse practitioner ask the patient. History: Complete appropriate health history. Physical Exam: Complete appropriate physical exam. EMR Documentation Chief Complaint and History of Present Illness 5 criteria using OLDCARTS: 1.) Complete; 2.) Accurate; 3.) Written in Professional Language; 4.) Pertinent to the Chief Complaint; 5.) Includes Subjective findings only EMR Documentation Subjective Data Document Current Medications, PMH, Allergies, Family History, Social History, Preventive Health, Review of Systems 5 criteria: 1.) Complete; 2.) Accurate; 3.) Written in Professional Language; 4.) Pertinent to the Chief Complaint; 5.) Includes Subjective findings EMR Documentation Objective Data Document Physical Exam Findings: 5 criteria: 1.) Complete; 2.) Accurate; 3.) Written in Professional Language; 4.) Pertinent to the Chief Complaint; 5.) Includes Objective findings only Key Findings: Organize the key findings with the most important first and least important last. Problem Statement: Document a brief and accurate problem statement using professional language that includes the following: 1.) Name or initials, age; 2.) Chief complaint; 3.) Positive and negative subjective findings; 4.) Positive and negative objective findings. Management Plan: Use the expert diagnosis provided to create pertinent, comprehensive, evidenced-based management plan. Address the following criteria in the plan: 1.) Diagnostic tests; 2.) Medications (write out a complete order, even for OTC meds); 3.) Suggested consults/referrals; 4.) Patient education; 5.) Follow-up, including time interval and specific symptoms to prompt a return visit sooner; 6.) Provide rationales for each intervention and include references to support your plan. Clinical practice guidelines should be utilized as applicable. References and Format: Current citations for references in management plan. Use of clinical practice guidelines when applicable.

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