Case Study

Below is the template you are to follow when developing your management plan. Also, always be sure to complete the EMR on the case. Use this template with each case. It is not a SOAP format as that is not required. Points will be deducted for not utilizing the template.

THIS SECTION IS 30 POINTS!!! Follow the bullet points below. Copy and answer each bullet point on a word document and cut and paste your responses to the management section!

 

  •  Primary Diagnosis and ICD-10 code: Also include any procedural codes.
  • 3-5 Differential Diagnoses- Why? What made you select each one as a DDX? How did you rule out? This would be a good area to include references.
  • Additional laboratory and diagnostic tests: It may be necessary to establish or evaluate a condition. Some tests, such as MRI, may require prior authorization from the patient’s insurance carrier.
  • Consults: referrals to specialists, therapists (physical, occupational), counselors, or other professionals. If you are sending it to the hospital, what orders would you write for a direct admit?
  • Therapeutic modalities: pharmacological and nonpharmacological management.
  • Health Promotion: Address risk factors as appropriate. Consider age-appropriate preventive health screening.
  • Patient education: Explanations and advice given to patient and family members.
  • Disposition/follow-up instructions: when the patient is to return sooner, and when to go to another facility such as the emergency department, urgent care center, specialist, or therapist.
  • References (minimum of 3, timely, that prove this plan follows the current standard of care).

Identifying data (ID):lb  a 76-year-old African American female that resides in an apartment on the second floor.

Chief complaint (CC): “I am having pain in my knees and I am ready to do something about it. That is why they sent me to you. My knees have been getting worse over the past couple of years. They hurt when I walk for more than a block and when I climb stairs. “

History of present illness (HPI)

Analysis of symptom/complaint:

·        Lb complains of pain in her knees that stared about five years ago but has gotten worse over time. The location of her pain is inside her knees, and the pain in her right knee is worse. The pain in her right knee radiates down to her ankle.  Ms. Johnson describes the pain in her knees as stiff and achy. They are stiff in the morning for about 15-20 minutes. Cold weather and exercise makes her knee pain worse. She hasn’t found anything that helps with the pain. Ms. Johnson states that her pain level is usually about a 4 or 5 out of 10, and sometimes it is a 7 or 8 out of 10. Associated symptoms with the pain are swelling in her knees and sometimes her finger knuckles.

has trouble getting around due the pain in her knees. Ms. Johnson states, “I have to walk up the stairs to get to it. Thank goodness I don’t live on the 3rd floor. It’s getting harder and harder to get up those stairs. My daughter usually has to come help me.”

a.          Include significant chronic health disorders that impact on the current chief complaint.

Ms. Johnson has a past medical history of peptic ulcer disease with GI bleed from Ibuprofen use, chronic kidney disease, and hypertension.

2.            Allergies: Ms. Johnson denies allergies to medication, food, pollens and pet dander (environmental).

3.            Immunizations:  Up to date

4.            Past medical history (PMH) –

a.          Past medical disorders/illnesses

Hypertension (for the last 20 years)

Chronic Kidney Disease

Peptic Ulcer Disease with GI bleed from Ibuprofen 4 years ago.

b.          Past surgical history (PSH)

No past surgical history

Injuries/disabilities

Patient reports no injuries or disabilities.

·        d.            Other hospitalizations B.

Medications

Amlodipine 10mg tab ,1tab po daily

Lisinopril 10mg tab,1 tab Po daily

Simvastatin 20mg tab

Hydrochlorothiazide 25mg tab

Acetaminophen prn headacge

Mulivitamin dsily