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Complete Case Study 1: Multi-Symptom according to the following:
You just got on shift. A 24 YOA Native-American male presents with fever, chills, malaise, anorexia, and weight loss that has lasted 2 weeks.
1. Past Medical History: Denies.
2. Past Surgical History: Tonsillectomy at age 10.
3. Medications: Denies.
4. Social History: Denies tobacco or alcohol use. States he does not have a permanent residence: “I sleep around on my friends’ couches.” Admits that he smokes marijuana occasionally, but that: “I haven’t partied in a while.”
5. Family History: Mother has DM Type 2 and cirrhosis of the liver. The father also has DM Type 2 and has had an MI.
1. Constitutional: Admits to fever, malaise, anorexia, and weight loss. He states that he lost 10 lbs. in the last week.
2. Neuro: Denies numbness, tingling, weakness, or loss of consciousness. He has generalized weakness.
3. Pulmonary: Complains of SOB with a cough, but no sputum production. Admits to some pleuritic pain. No hemoptysis.
4. Cardiac: Denies chest pain. Denies palpations or edema.
5. GI: Admits to some nausea, vomiting, and diarrhea.
Physical Examination Findings:
1. Vital Signs: Temp: 39.9, HR 126, BP 84/40, RR 22, O2 Sat 87% on 4LNC.
2. Lab Values: WBC count is 24.
3. ABG: 7.25, PO2 is 78, PCO2 is 30, and HCO3-is 11.
4. Imaging: Chest CT with contrast reveals multiple round densities and cavitations with hilar adenopathy in the lung tissue.
5. General Status: Patient is ill-kempt. He is cachectic. He appears older than his stated age. He presents moaning on a stretcher.
6. HEENT: Dry mucous membranes. Exhibits a 2cm linear R forehead laceration, healing with sutures.
7. Neurological Status: Lethargic. Confused. Opens eyes only with deep sternal rub. Does not follow commands. Moves all extremities 3/5.
8. Pulmonary Status: Diminished throughout.
9. Cardiovascular Status: S1 and S2 clear with tachycardia noted, regular rhythm. Pulses 2+ bilaterally in radial, femoral and pedal pulses. Systolic murmur noted. No edema noted.
10. Skin: Multiple areas of bruising and wounds of various sizes and stages of healing in bilateral antecubital fossae, and between the toes on both feet. Painful, erythematous, raised lesions are found bilaterally on both hands and feet.
Evaluate this case and determine three differential diagnoses for the patient’s presenting symptoms. Support your rationale by discussing the pertinent positive and negative findings from the patient’s history and physical examination for each differential diagnosis. Further support your rationale with three to five sources from the current research literature.
Address the following in your analysis:
1. What do you think is the final diagnosis that is causing the patient to seek care at this point? Explain your rationale?
2. What other questions would you ask your patient or what physical exam findings would you look for to help you confirm your final diagnosis?
3. In general, what are the risk factors for the final diagnosis?
4. How might the final diagnosis present differently for geriatric patients?
5. What labs, diagnostics, or clinical tests do you need to confirm your final diagnosis and rule out your other differential diagnoses? What is the rationale for each?
6. Create the problem list for this patient. What is your rationale? Consider all of the patient’s acute and chronic diagnoses.
7. What is your evidenced-based plan of care for the final diagnosis? Provide a detailed rationale? Which evidence-based guidelines will you use to help inform your plan of care?
8. Write admission orders for your patient. Consider all of the patient’s acute and chronic diagnoses in your problem list. Include rationale for each order you write.
9. Anticipate the needs of this patient. What immediate and long-term complications is the patient at risk for based on the information in the case? What orders, education, and recommendations will you provide to prevent complications for the patient while under your care and in the future?
10. Based on the patient’s age, race, gender, and diagnoses mentioned in the case, what health promotion/clinical preventative services do you recommend for this patient?
Prepare this assignment according to the guidelines found in the APA Style Guide, located in the Student Success Center. An abstract is not required.
This assignment uses a rubric. Please review the rubric prior to beginning the assignment to become familiar with the expectations for successful completion.
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