How to Answer Using This Case Questions (Complete Guide)

Students often encounter this when studying fundamental concepts.

What This Question Is About

This question relates to using this case and requires a structured academic response.

How to Approach This Question

Structure your response with introduction, analysis, and conclusion.

Key Explanation

This topic involves using this case. A strong answer should include explanation, application, and examples.

Original Question

USING THIS CASE SCENARIO PROVIDE A WELL DETAILED INFORMATION. Case scenario. This patient is a 72-year-old female with a past medical history of hypertension, hyperlipidemia, type 2 diabetes mellitus, overweight BMI, and a former smoker with a 40-pack-year history of smoking. Patient presents with 2 weeks of worsening exertional dyspnea, she becomes short of breath running after grandchildren, relieved by 10 minutes rest. Reports fatigue worsened with exertion, presyncope without syncope or falls. Vitals are within normal limits, and physical exam reveals a displaced PMI and new grade III systolic ejection murmur heard over the right upper sternal border radiating to the carotid arteries. No signs of edema or fluid overload are present. Patient reports allergic to lisinopril and losartan (lip swelling, difficulty breathing. She denies chest pain, palpitations, alcohol or drug use, fever, weight loss or weight gain, nausea, or vomiting. Medications: Amlodipine 10 mg, Metformin 1000 mg, Simvastatin 40 mg, Hydrochlorothiazide 25 mg. Family History: Mother (deceased at age 74) had type 2 diabetes mellitus and hypertension. Father (deceased at age 70) had chronic obstructive pulmonary disease, type 2 diabetes mellitus, and hypertension. Sister living, (age 71) has type 2 diabetes mellitus, hypertension, and stage 1 cervical cancer. Children: Son (age 45) and daughter (age 43) are healthy with no known medical problems. QUESTIONS: Write a Problem Statement. Primary Diagnosis with coding. Patient diagnosis is Aortic valve stenosis. Include introductory paragraph as it relates to the primary diagnosis. Primary diagnosis with ICD-10 codes. Rationale for primary diagnosis. Include CPT code/s for office visit or preventive exam. Also include any CPT codes for procedures performed during this visit – i.e.: vaccine, lab draw, ear lavage. Evidence-based guidelines: Which guidelines were used to develop the primary diagnosis? provide a detail explanation relating to the evidenced based guideline that was used. Differential Diagnoses a. Include 5 differential diagnoses (different from the primary diagnosis) b. Rationale for each diagnosis. Include tests to be ordered to confirm the primary diagnosis of Aortic valve stenosis. Any ancillary testing needed – i.e.: ECG, Spirometry, X-ray etc. Management Plan, include: List Medications to be prescribed for this patient, with reference to her previous medications she is already taking. include Drug name, dosage, route, frequency, any refills. Include any supplements or OTC medications. Include education for prescribed medications. Include Nonpharmacological treatment/supportive care. Referrals – any specialty referrals – i.e.: physical therapy, cardiology, hematology. Etc. SDOH, health promotion and risk factors a. SDOH – Address economic stability, education access and quality, healthcare access and quality, neighborhood and environment, and social and community domains for the patient. b. Health promotion – include all age-appropriate preventive health screenings and immunizations. c. Risk factors – Address patient risk factors related to primary diagnosis of aortic valve stenosis. Patient Education a. Include comprehensive patient education related to current health visit 8. Follow up a. Include time for the patient’s next visit and specific symptoms to prompt a return visit sooner. Include a conclusion paragraph 9. References a. Must use a minimum of 6 scholarly references within the past 5 years. ( 2020-2025).

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