Julie is a 35 year old African American female who complains of a sore throat? for the past 3 days. ?NUR631LFocusedCaseStudy1.docx

NUR631-L

Focused Case Study # 1

Julie is a 35 year old African American female who complains of a “sore throat” for the past 3 days. Julie was concerned because it is not getting any better, only worse. She had her friend look in her throat at work and was told to go to her primary care office for evaluation. Julie was also concerned because she saw some redness on the back of her throat. Julie states that when she tries to swallow “it feels like she is swallowing knives.” She has been having a hard time eating and drinking due to the pain. She has noted bad breath throughout the day over the past three days. She tried to take a Tylenol at home yesterday, but the pain did not improve. She admits to coughing occasionally. She gives the pain in her throat a 7/10 on the pain scale.

Julie works as a receptionist at a car-dealership. She is an avid outdoor enthusiast. She hikes regularly, and tries to travel when she can to tropical locations. Her last trip was a few weeks ago. She traveled by airplane to Puerto Rico. She drinks wine socially; admitting to 2-3 glasses a few nights a week. She denies smoking. She is married. Julie’s husband is 39yo, and she has a 3yo son. Her husband has HTN, and her son has asthma. Julie uses albuterol as needed for her asthma, as she was diagnosed at age 14. She also takes lisinopril 5mg once daily for her HTN. She is allergic to shrimp, and latex. She develops anaphylaxis to shrimp and body wide rash to latex. Julie has a mother 65yo (HTN, HLD, CVA), and a father 68yo (CAD, HTN, HLD, DM).

She admits to having her gallbladder removed at age 27, and a skin lesion biopsied at age 30 with her dermatologist.

VS: T: 99.8, HR: 109, BP: 150/68, RR: 14 HT: 5’8, WT: 170lbs

EKG: Sinus Tachycardia, without ST elevation or depression

PE:

Julie appears unwell. She walks herself into the exam room in NAD, but looks fatigued. Head atraumatic, normocephalic. EOMI, PERRLA, 2+, BL red reflex intact. No nasal polyps or discharge. Pharynx with BL tonsillar exudates, 3+R, 2+L. Uvula midline, but edematous. Tongue with strawberry patches. BL cervical lymphadenopathy noted to palpation. Skin is appropriate for ethnicity, no lesions, rashes, warm to touch. Heart with normal s1/s2, no murmur auscultated. Lungs clear posteriorly, BL. Abdomen SNTTP. 2+ pulses in BL upper and lower extremities. Neurologically intact, without focal deficit.

Instructions: Reformat the above data as follows from Bates:

Your must include a full ROS and Physical Exam for full Credit

1). CC:

HPI

PMH (include surgeries and traumatic injuries)

Current medications

Allergies

Psychosocial

Family History – genogram (you can draw it and place on last page, or create in word document)

ROS – complete information

Physical Exam – complete information

2). List 3 Differential Diagnoses in descending order of suspicion

(Number these as #1, #2, #3, your #1 should be your primary working DX)

3). List the pertinent positives/negatives to support your differentials. (at least 3 of each)

4). List additional history data that would support your primary differential diagnosis and why? (At least 10 history questions listed)

5). List any additional physical components that would support your primary differential diagnosis and why? (At least 5 PE findings that would better help you diagnose your primary differential)

6). Select your primary differential diagnosis as #1 and include 2 other differentials:

a) Give a brief pathophysiologic description of each disorder (< 10 sentences)

b) Etiology (primary dx)

c) Usual clinical findings or features (primary dx)

d) Diagnostic criteria (if any) for making the diagnosis (primary dx)

e) Treatment Plan – include specific treatments like pharmacotherapy (be specific with doses, amounts, etc) (for your PRIMARY DX)

Health History Chapter 3, ROS page 101-106 Bates, Complete PE 132-133 Bates

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