Case Study Question Question & Answer Guide (With Explanation)

This question focuses on applying theory to practical scenarios.

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Key Explanation

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Original Question

case study question History: Mr. J is a 56 year old male, who presented to your office today for complaints of chest pain. He states that his pain has been occurring intermittently for 3 days. He admits that with any strenuous activity he develops this pain in his chest. When he points to the area where he is describing, it is by his left areola. He states he has been fatigued, and very “winded” with any exertion. He denies any recent travel, and denies any sick contacts at home. He has been vaccinated for COVID with 3 vaccines. He denies any history of PE/DVT. Denies any extremity swelling or pain. He denies cough. He has had poor appetite over the past 3 days. Denies nausea, vomiting or diarrhea. He admits that last evening while sitting on his couch, he has “pins and needles” in his left arm, which went all the way to his fingertips. He smokes 1 pack of cigarettes a day. Has a “chronic cough” he states. PMHX: HTN, HLD, CAD, DM, COPD (not on home oxygen), GERD Medications: Lisinopril 10mg Once daily, Norvasc 5mg Daily, Lipitor 40mg once daily, Pepcid 20mg BID, Ventolin Inh. PRN Q6hours, Metformin 500mg BID Surgical HX: CABGX2 (2020) FHX: Mother(87yo) COPD, HTN, CAD, Father (89yo)Deceased d/t MI, Wife (50yo) HTN, COPD, Daughter (30yo) Healthy, Son (32yo) Schizophrenia, Daughter (34yo) HIV Social HX: Smokes 1PPD of cigarettes, occasional cocaine use, ETOH use (6-9 beers/week) VS: Temp 98.7 oral, HR 99, BP 150/65, RR 16, SPO2 97% RA HT:5’7″, WT: 260lbs Physical Exam: This is a 56yo Caucasian mal, appears states age. Tobacco stained fingernails. A&OX3, Well dressed. Oral mucosa pink, moist, intact. Poor dentition with multiple areas of plaque/dental caries. EOMI, PERRLA 2+ BL, Neck supple, no palpable thyroid. No JVD or cervical lymphadenopathy. Chest wall without pain to palpation, no rashes/lesions noted. Lungs with scattered wheezes/rhonchi that clear with coughing. No egophony, bronchophony, or whispered pectoriloquy. Heart with normal s1/s2, no murmur appreciated to auscultation. 2+ pulses in BL upper and lower extremities. Calves are symmetric, temperature intact BL, with negative homan’s sign BL. 1+ edema in BL lower extremities. ROM intact in all joints. ABD is SNTTP, BS X 4. Diagnostic Studies: EKG Normal Sinus Rhythm, Hgb 10.5, Plts 250, BUN 25, CREA 0.9, Na 135, K 3.7, Glucose 140, BNP 98 GRADING SHEET FOR NUR 631 HISTORY DATA- 40 points HX pts____ Chief Concern (CC) (8) ____ Complete History of Present Illness (HPI) (12) ____ Pertinent PMH (meds, allergies, social risks) (4) ____ Review of Systems (Case data documented appropriately) (12) ____ Family History (with genogram) (4) ____ PHYSICAL EXAM – 40 points PE pts_____ Case data appropriately documented in FULL PE DIFFERENTIAL DIAGNOSIS – 10 points DD pts____ List 3 Differentials to explain primary problem (3@1ea=3) ____ Give a brief pathophysiologic description of each DD: (3) Etiology ____ Usual clinical findings or features ____ Pertinent positives/negatives listed to support primary DD (2) ____ List additional history questions to support primary DD (1) ____ List additional physical findings to support primary DD (1) ____ PLAN OF CARE -5 points Plan pts___ (specific treatments including meds – be specific with doses, times) Pharmacologic (2) ____ Non Pharmacologic (1) ____ Patient Education (1) ____ Follow Up (1) ____ *Neatness, typed, submitted on time, appropriate format, use of appropriate terminology, references – 5 points Form pts___ Total poin

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