Case study Martha Krauntz

NSG 5540 CASE STUDY TEMPLATE

Title page – including the identified case study name and number

Learning Issues – what do you need more information in order to develop a plan? If so, what information do you need or want? (Can be bullet points)

  • Example – Chest Pain
  • How do you evaluate a patient with a history of chest discomfort and risk factors for heart disease?
  • What are the laboratory findings that are important to look for with someone with chest discomfort?
  • How do you manage abnormal lipids?
  • What lifestyle changes are important to recommend to reduce cardiac risk

Interpretation of Cues, Patterns, and Information – symptoms analysis and identification of any missing data that would helpful in making a plan for care (Can be bullet points)

  • Example – Chest pain
  • Chest discomfort – musculoskeletal vs gastrointestinal vs cardiac vs respiratory?
  • What labs are missing that would assist in the planning process for this patient?
  • Family history that could increase risk of cardiovascular disease
  • Psychosocial issues – caffeine intake, smoking, ETOH use, or working history

Differential Diagnoses – include 3 differential diagnoses including ICD-10 codes (Can be bullet points)

  • Example – Chest pain RO7.9

                         Precordial Pain – R07.2

                                    Acute Myocardial Infarction – I21.9

                                    Gastroesophageal Reflux Disease without esophagitis– K21.9

Diagnostic Options – what additional laboratory work, diagnostic testing, or possible referrals may be required? (Can be bullet points)

Final Diagnosis - what is the most probable cause of the patient problem?

Therapeutic Options – this is related to your final diagnosis (Paragraph Form or Bullet Points)

  • Pharmacological
  • Nonpharmacological
  • Educational
  • Social Determinants of Health

Follow up – when should this patient return to the office? What conditions would need earlier follow up? (Paragraph Form)

Respond to at least 2 peers with meaningful responses and respond to faculty-you may constructively critique peer cases, use rationales and citations

References page (APA Format). Do not use references greater than 5 yrs old. 

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