Case Study Discussion: Module 6, Case Study 2
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Analyze this case as you would a client in a clinical setting. You may use your class texts, your pathophysiology text, peer-reviewed journals, and any other reputable sources necessary to help you plan care for this client.
Read the following case study:
Subjective data:
Patient initials: ST
Age: 16
Gender: M
Ethnicity: Caucasian
Allergies: NKDA
Informant: mother
Last Clinic Visit: 1 month ago (in January) with URI
Parents/Living status: married
Siblings (age and gender): sister, age 14 years; brother, age 6 years
Family History: maternal grandmother with hypertension and father has gout history; mother has fibromyalgia
Past Medical History: sprained ankles due to soccer 2 years ago; chickenpox as a 2-year-old; frequent episodes of tonsillitis
Past Hospitalizations/Injuries: none
Development/School Issues: average student; active in extracurricular activities and sports; makes friends readily
ROS: fever, aches, sore throat, cough, nasal congestion checked on patient self-report form
Activities of Daily Living:
Immunizations: current
Current medications: none
Chief complaint: Feeling tired and achy for weeks now
HPI: Patient reports with mother and c/o increased fatigue and body aches over the last 2 weeks. + congestion and cough with progressively worsening sore throat, decreased appetite. Low grade fevers, + headaches on and off- not waking him up at night, no double vision or blurred vision, no N/V. No one sick at home.
Objective data:
Height
Weight: 101 lbs.
Temperature: 101.0
Heart Rate: 80
: 16
Blood pressure: 110/60
BMI:
General appearance: patient appears fatigued
Skin: no rashes, lesions, or ulcerations
Head: symmetrical
Eyes: PERRLA, red reflex present
Ears: TMs pearly; nontender
Nose: turbinates edematous with some cloudy nasal drainage noted
Mouth/Throat: pharynx slightly red posterior, tonsils enlarged with a shaggy grey exudate, scattered palatal petechiae
Neck: enlarge nontender thyroid no nodules
Chest and Lungs: bilateral CTA without wheezing
Breast:
Heart: regular rhythm without murmurs or gallops
Abdomen: positive bowel sounds; no liver enlargement, minimal TTP noted, LUQ and spleen palpable 3cm below the costal margin
Genitalia: not assessed
Rectum/Anus: not assessed
Musculoskeletal: MAE
Neuro: +1 DTRs all extremities; CN 2-12- intact, no nuchal rigidity, interacting appropriately
CBC Results:
WBC: 9.5 (4.5-10.5)
LY: 17.4 (20.5-51.1)
MO: 10.4 (1.7-9.3)
GR: 72.2 (42.2-75.2)
RBC: 3.51 (4.00-6.00)
HGB: 10.6 (11.0-18.0)
HCT: 32.1 (35-60)
MCV: 91.7 (80.0-99.9)
MCH: 30.2 (27.0-31.0)
MCHC: 33.0 (33.0-37.0)
RDW: 12.4 (11.6-13.7)
Post a response to the following assessment and plan by 11:59PM (EST) on Thursday:
Assessment:
Provide the diagnosis.
Provide the differential.
Provide rational for this diagnosis.
Plan:
Describe the diagnostic tests ordered (any pending labs go here). This must be supported by the diagnosis and differential.
Provide treatments for this problem (medications and other therapeutic measures). Provide recommendations for this diagnosis only.
Include any health maintenance concerns of immunizations, nutrition, growth and development, and safety. Include anticipatory guidance.
Explain cost concerns with this treatment or community resources.
Recommend a follow-up (when patient should call or RTC).
Determine if a referral is needed.
List references here, and summarize in your own words the current research on this diagnosis and plan of care. List national guidelines used.
Address any sociocultural, financial, or other considerations.
Cite at least 1 relevant article within the last 5 years to support your claim.
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