Case Study Care Plan

Case Study Care Plan

Please use this scenario below to answer the questions and create a history, physical, assessment and plan/treatment. Please feel free to make up patient information to match story line an treatment plan.

May use references as needed app format

A 16-year-old girl presents for a preparticipation physical. A review of systems reveals that her menstrual cycles have been irregular since she started training for the cross-country season. She admits to being a picky eater but denies restricting food intake, binge eating, or self-induced vomiting. She has no significant medical history. She is not on any medications. Her body mass index is 18.5 kg/m2. A urine pregnancy test in the office is negative. For which of the following is she at greatest risk?

Basic structure:

Identifying information/chief complaint

History of present illness

Other active medical problems, medications, habits, and allergies

Physical Examination- key findings

Labs

Physical examination (key findings only)

Check tips on how to do your Medical Research Paper. 

Case Study Care Plan

 Identifying information/chief complaint: 20 points
Content – contains 4 elements, expressed in a single sentence

The patient’s age and sex

The patient’s active ongoing medical problems, mentioned by name only, and including only the most important, i.e., no more than 3 or 4

The patient’s reason for presentation

The duration of symptoms

History of Present Illness:  20 points
The fundamental part of the oral presentation and the source of 90% of correct diagnoses.
Content

All “positive” elements (i.e., what occurred) precede all “negative” elements (what was absent)

“Positive” statements a. Are presented in chronologic order b. Are attentive to detail b c. If the current problem is a direct extension of a previous ongoing active medical problem, the HPI begins with a 1-2 sentence summary of that ongoing medical problem, using “key words”: 1. Date of diagnosis? 2. How was diagnosis made?

Current symptoms and treatment?

Are any complications present?

Are any objective measures of the chronic problem available? (e.g., a1c for diabetes)

Case Study Care Plan

Other active medical problems, medications, social history, and allergies: (10 points)

Brief summary (using key words, see previous) of other active medical problems mentioned in your identifying information sentence but not discussed in HPI.

Social history- smoking, alcohol, drug, and/or vaping/e-cigarette use

Medications – give dosages

Physical examination 

Begin with “general description and vital signs”

Include all abnormal findings

Among normal findings, include only those essential to the understanding of the chief Complaint

Laboratory )

Include all abnormal labs, with comparison to previous value

Among normal labs, includes only those relevant to the chief complaint

Any labs presented should appear in traditional order (electrolytes/creatinine/glucose,complete blood count, other chemistries, urinalysis, vaginal culture, transvaginal ultrasound

Case Study Care Plan

 Assessment & Plan 

Begin with a positive statement of the patient’s problem, which is either a (1) symptom, (2) sign, (3) abnormal laboratory test, or (4) diagnosis. Choose the highest number on this list  that no one could argue with (e.g., if the patient has pelvic pain and a 4 cm simple ovarian cyst, the assessment focuses on the abnormal lab “ 4 cm”).

Ask yourself “At the moment I am presenting the case, what is the principal unresolved issue”

If the principal unresolved issue is diagnosis, your assessment focuses on differential diagnosis: (i) list the 3-5 most likely diagnoses, (ii) state which diagnosis is most likely and why, and (iii) state why other diagnostic possibilities are less likely (draw your evidence from the H and P you just presented)

If the principal unresolved issue is therapy, your assessment should: (i) state the diagnosis or problem, (ii) state which therapy you gave or plan to give, and why you made this decision, (iii) state which complications you might anticipate

If you are presenting the morning after overnight call, the case presentation usually ends with a 1-2 sentence summary of what happened overnight, after implementation of your initial decisions

The assessment and plan focus only on those active issues keeping the patient in the hospital (stable outpatient problems are included in your write-up are omitted in the inpatient case presentation).