Posted: September 19th, 2022

Focused Case Study # 1

 Julie is a 35 year old African American female who complains of a “sore throat” for the past 3 days.  

NUR631-L

Focused Case Study # 1

Julie is a 35 year old African American female who complains of a “sore throat” for the past 3 days. Julie was concerned because it is not getting any better, only worse. She had her friend look in her throat at work and was told to go to her primary care office for evaluation. Julie was also concerned because she saw some redness on the back of her throat. Julie states that when she tries to swallow “it feels like she is swallowing knives.” She has been having a hard time eating and drinking due to the pain. She has noted bad breath throughout the day over the past three days. She tried to take a Tylenol at home yesterday, but the pain did not improve. She admits to coughing occasionally. She gives the pain in her throat a 7/10 on the pain scale.

Julie works as a receptionist at a car-dealership. She is an avid outdoor enthusiast. She hikes regularly, and tries to travel when she can to tropical locations. Her last trip was a few weeks ago. She traveled by airplane to Puerto Rico. She drinks wine socially; admitting to 2-3 glasses a few nights a week. She denies smoking. She is married. Julie’s husband is 39yo, and she has a 3yo son. Her husband has HTN, and her son has asthma. Julie uses albuterol as needed for her asthma, as she was diagnosed at age 14. She also takes lisinopril 5mg once daily for her HTN. She is allergic to shrimp, and latex. She develops anaphylaxis to shrimp and body wide rash to latex. Julie has a mother 65yo (HTN, HLD, CVA), and a father 68yo (CAD, HTN, HLD, DM).

She admits to having her gallbladder removed at age 27, and a skin lesion biopsied at age 30 with her dermatologist.

VS: T: 99.8, HR: 109, BP: 150/68, RR: 14 HT: 5’8, WT: 170lbs

EKG: Sinus Tachycardia, without ST elevation or depression

PE:

Julie appears unwell. She walks herself into the exam room in NAD, but looks fatigued. Head atraumatic, normocephalic. EOMI, PERRLA, 2+, BL red reflex intact. No nasal polyps or discharge. Pharynx with BL tonsillar exudates, 3+R, 2+L. Uvula midline, but edematous. Tongue with strawberry patches. BL cervical lymphadenopathy noted to palpation. Skin is appropriate for ethnicity, no lesions, rashes, warm to touch. Heart with normal s1/s2, no murmur auscultated. Lungs clear posteriorly, BL. Abdomen SNTTP. 2+ pulses in BL upper and lower extremities. Neurologically intact, without focal deficit.


Instructions: Reformat the above data as follows from Bates:

Your must include a full ROS and Physical Exam for full Credit

1). CC:

HPI

PMH (include surgeries and traumatic injuries)

Current medications

Allergies

Psychosocial

Family History – genogram (you can draw it and place on last page, or create in word document)

ROS – complete information

Physical Exam – complete information

2). List 3 Differential Diagnoses in descending order of suspicion

(Number these as #1, #2, #3, your #1 should be your primary working DX)

3). List the pertinent positives/negatives to support your differentials. (at least 3 of each)

4). List additional history data that would support your primary differential diagnosis and why? (At least 10 history questions listed)

5). List any additional physical components that would support your primary differential diagnosis and why? (At least 5 PE findings that would better help you diagnose your primary differential)

6). Select your
primary differential diagnosis as #1 and include 2 other differentials:

a) Give a brief
pathophysiologic description of
each disorder (< 10 sentences)

b) Etiology (primary dx)

c) Usual clinical findings or features (primary dx)

d) Diagnostic criteria (if any) for making the diagnosis (primary dx)

e) Treatment Plan – include specific treatments like pharmacotherapy (be specific with doses, amounts, etc) (for your PRIMARY DX)

Health History Chapter 3, ROS page 101-106 Bates, Complete PE 132-133 Bates


Case Study 1 – Julie

1) History Data

a. Chief Concern (CC)

· Julie complains of a “sore throat” for the past three days that keeps getting worse and “feels like she is swallowing knives.” She rates the pain in her throat as 7/10.

b. Complete History of Present Illness (HPI)

· Julie is concerned that there is redness in the back of her throat, and she has been having a hard time eating and drinking due to the pain. She also notes bad breath throughout the day for the past 3 days and has been coughing occasionally. Her last trip was a few weeks ago where she travelled by airplane to Puerto Rico.

· Medications:

1. Albuterol for asthma

2. Lisinopril 5mg QD for HTN

· Allergies: Shrimp & latex

· Tobacco use: Non-smoker.

c. Pertinent Past Medical History (PMH) (include surgeries and traumatic injuries)

· Childhood illnesses: Asthma (diagnosed at aged 14)

· Adult Illnesses

1. Medical: Hypertension (HTN), Asthma,

2. Surgical: Gallbladder removal (age 27),

3. OBGYN: Not reported

4. Psychiatric: No reported psychiatric illnesses

5. Other: Skin lesion biopsy at age 30 –

Health Maintenance Practices

1. Immunizations: Not reported

2. Screening tests: Skin lesion biopsy at 30 years old with a dermatologist.

3. Lifestyle issues: Non-smoker, occasional wine drinker (2-3 glasses a few nights a week). No reported drug use. Outdoor enthusiast, hikes regularly.

4. Home safety: Married and has a 3-year-old son. No domestic issues reported.

· Surgeries: Gallbladder removal at age 27.

· Traumatic injuries: No reported traumatic injuries.

· Current medications: (stated above)

· Allergies: Shrimp and Latex

· Psychosocial: Receptionist at a car dealership.

· Other: N/A

d. Family History

· Mother – 65 y/o, with hypertension, hyperlipidemia, and cerebrovascular accident.

· Father – 68 y/o, with hypertension, hyperlipidemia, coronary artery disease, and diabetes mellitus.


Please see last page for genogram

2). Review of Systems (ROS)

·
General: Febrile (T:99.6), appears fatigued, and does not report weight changes.

·
Skin: Appropriate for ethnicity. No lesions, rashes, skin warm to the touch.

·
Head, Eyes, Ears, Nose, Throat (HEENT):

1.
Head: No head trauma, normocephalic. No reported dizziness, headache, or vertigo.

2.
Eyes: Extraocular muscles intact, PERRLA, BL red reflex intact. Doesn’t report vision problems, no noted tearing, redness, pain, glaucoma, or cataracts.

3.
Ears: No reported hearing problems, vertigo, ear infections, tinnitus, or discharge.

4.
Nose: No discharge or nasal polyps, patient doesn’t report issues with upper respiratory bleeding, or infection.

5.
Throat (or mouth or pharynx): Pain 7/10 in the throat. Pharynx with bilateral tonsillar exudates, 3+R, 2+L. Uvula is midline and edematous. Tongue has strawberry patches.

Neck: Bilateral cervical lymphadenopathy noted on palpation.

Respiratory: Patient reports occasional cough, but does not report shortness of breath, pain with breathing, or wheezing. Lungs are clear posteriorly and bilaterally.

Cardiovascular: Heart sounds detect normal s1/s2, and no murmur revealed on auscultation.

Patient has hypertension (BP: 145/68) but is managing her blood pressure with lisinopril 5mg.

Patient has sinus tachycardia without ST elevation or depression. Patient’s heart rate is 107.

Doesn’t report any palpitations, chest pain, dyspnea, or orthopnea from given information.

Gastrointestinal: Patient reports pain with swallowing, but denies indigestion, nausea, or vomiting. No reported diarrhea, rectal bleeding, hemorrhoids or change in stool color. Patient had her gallbladder removed. Abdomen soft, non-tender to palpation.

Urinary: No reported urinary urgency, frequency, hematuria, flank pain, burning, or pain upon urination. No known kidney disease, stones, or incontinence.

Genital: Patient does not report any history of genital infections or discomfort. Patient has one partner (husband) from given information. Patient does not report contraception methods, or history of sexual transmitted infections.

Peripheral vascular: No reported leg pain or swelling. 2+ pulses bilaterally in upper and lower extremities.

Musculoskeletal: Patient walks herself into the exam room in no distress but looks fatigued. No report of joint stiffness, pain, or gout. No past traumas noted. No identified pain on activity.
Psychiatric: Patient is alert and oriented to time, place, and person. No reports of anxiety, depression, or memory changes. Patient’s speech is normal and appropriate, with no changes in judgement or memory. No history of psychiatric disorders.

Neurologic: She is neurologically intact, without focal deficit. No reports of headache, fainting, seizures, or vertigo. Patient denies paralysis, sensation of tingling, numbness, or “pins and needles.” No evident tremors or involuntary movements.
Hematologic: No reports of bruising, bleeding, or anemia.

Endocrine: No reports of excessive hunger or thirst, cold or heat intolerance, weight gain or loss, or hirsutism.

3). Physical Exam

General Survey: Julia is a 35-year-old African American female, appears tall, overweight, wellgroomed, responsive to questions, and shows no discomfort other than the pain in her throat.

Vital Signs: Height (Ht) 172.72cm (5’8”). Weight (Wt) 86.2kg (190 lbs.). BMI 28.9, (overweight). Blood pressure (BP) 145/68. Heart rate (HR) 107 beats per minute, sinus tachycardia. Respiratory rate (RR) 16, on room air. Temperature (T) 99.6oF.

Skin: Julie’s skin complexion is even, appropriate for ethnicity. Skin is warm to touch with no visible lesions, rashes or vesicles on noted. There are no signs of jaundice or noted discoloration.
Head, Eyes, Ears, Nose, Throat (HEENT):
Head: Normocephalic, atraumatic. Hair is evenly distributed, no visible lesions on scalp.
Eyes: Bilateral red reflex intact. Extra-ocular muscles intact, PERRLA, 2+. Conjunctiva is pink with white sclera, visual fields are normal, vision in each eye is 20/20 without correction.
Ears: Right and left auricles are clear, even color, and free of exudate. Right and left tympanic membrane is pearly gray in color, intact, and semitransparent. Voice-whisper test normal (patient can repeat words at 2 feet). Weber test shows equal hearing on both sides, Rinne test is normal (AC >BC).
Nose: Free of discharge or polyps. Mucosa is pink with septum midline. No sinus discomfort, bleeding, or breathing complications through the nasal cavity.
Mouth: Oral mucosa is moist with redness in the back of the throat. Pharynx with bilateral tonsillar exudates, 3+R, 2+L. Uvula is midline but edematous, tongue has strawberry patches.

Neck: Trachea midline. Neck is supple. Thyroid unpalpable.

Lymph nodes: Bilateral cervical lymphadenopathy on palpation.

Thorax and Lungs: Lungs are clear posteriorly, bilaterally. Patient is comfortably breathing in room air. Thorax is symmetrical anteriorly and posteriorly. Breath sounds are clear and lungs are resonant on percussion.

Axillae, and Epitrochlear Nodes: Nipples are normal shape, no discoloration, cracks, or discharge.

Cardiovascular System: Heart with normal S1 and S2, no murmur, rub, or gallop on auscultation. No jugular venous distention. No abnormalities in carotid pulses, no bruits or thrills noted. Apical pulse reveals no murmurs or splitting of S1 and S2. 2+ bounding pulses in bilateral upper and lower extremities with no edema noted. EKG shows sinus tachycardia without ST elevation or depression.

Abdomen: Abdomen is round, soft, non-tender to palpation. No visible or palpable masses or hepatomegaly on palpation. No tenderness in the costovertebral area. No guarding or rebound noted. Kidneys and spleen are not felt.

Extremities: Skin is warm to touch. No edema, discoloration, ulcers, or varicose veins noted. 2+ regular pulses in upper and lower extremities. Calves not red, swollen or-tender. Negative Homan’s sign bilaterally.

Musculoskeletal: No swelling or deformity noted in bilateral upper and lower extremities. Good range of motion in knees, hips, ankles, shoulders, elbows, head, and wrists. No pain on flexion and extension of the arms and legs. Neck flexion and extension normal. No localized tenderness.

Neurologic:
Mental status: Alert and oriented X3 (place, person, and time). Appropriate affect, responsive and cooperative.
Cranial nerves: I-XII intact.
Motor. Strength 5/5 in upper and lower extremities bilaterally.
Cerebellar: Stable gait, heel to toe walk intact, point to point movement test normal.
Sensory: Romberg test negative. Senses to light touch, vibration, pinprick intact.

Reflexes 2+ and normal in biceps, brachioradialis, Achilles, triceps, patellar, and plantar.

Babinski sign negative.

Back: Spine is straight and midline. Shoulders are symmetrical with even range of motion. Full range of motion and bending of the back. No localized tenderness.

Genital: External genitalia has no visible discharge, sores, or swelling. Patient denies pain on urination, during intercourse, or during menses. Patient has one partner (husband) from given information. Denies use of condom.

Rectal: No perirectal lesion or fissures. Rectal vault without masses. External sphincter tone intact. Stool normal color and negative for fetal occult blood.

4). List 3 Differential Diagnoses in descending order of suspicion (your 1st differential should be your primary).

1. Group A streptococcal pharyngitis

2. Infectious mononucleosis

3. Scarlet fever

6). List the pertinent positives/negatives to support your primary DD

Group A streptococcal pharyngitis

Positive sore throat

Positive for infection

Positive for cough

Negative body aches and chills

Negative for rash

Negative nausea & vomiting

Infectious mononucleosis

Positive lymphadenopathy

Positive fatigue

Positive for infected tonsils

Negative for swollen spleen

Negative for jaundice

Negative for skin rash

Scarlet fever

Positive tongue with strawberry patches

Positive sore throat

Positive for lymphadenopathy

Negative for red rash

Negative for blanching

Negative for flushed face

7). List additional history data that would support your primary differential diagnosis and why?

1. Do you have any trouble breathing?

Rationale: With infectious pharyngitis, the bacteria may cause a local inflammatory response that can cause airway obstruction.

2. Are you unusually tired or exhausted?

Rationale: With bacterial pharyngitis, the patient may suffer from general malaise and exhaustion.

3. Do you have any other symptoms of abdominal pain, nausea, and vomiting?

Rationale: These additional GI symptoms are common with Group A Strep.

Pharyngitis.

4. Have you recently been exposed to large crowds of people within the last week? Rationale: Transmission of Group A pharyngitis is typically acquired in crowded areas.

5. Do you know to have eaten anything new or skeptical in the last week?

Rationale: Some outbreaks of pharyngitis may occur due to improper food handling.

6. Have you recently been in contact with a person known to have a sore throat?

Rationale: Transmission of Group A pharyngitis is commonly spread through person-person contact.

7. Do you have any other symptoms of hoarseness, runny nose, or conjunctivitis?

Rationale: These additional viral symptoms can help confirm the diagnosis of

Group A Streptococcal Pharyngitis.

8. Do you feel body aches?

Rationale: Since the patient has a low-grade fever, it is very common to have body aches with Group A Streptococcal Pharyngitis.

9. Do you have chills where your body is shaking?

Rationale: In addition to body aches, the viral infection may cause chills and body shakes.

10. Have you noticed any recent changes in your appetite?

Rationale: Often with viral infections patients may present nausea and loss of appetite, which can cause nutritional deficiencies.

8). List any additional physical components that would support your primary differential diagnosis and why?

1. “Sore throat” for the past 3 days

Rationale: This is a symptom is typical of Group A Strep. Pharyngitis. The Incubation period is 2-5 days.

2. Difficulty swallowing due to pain and doesn’t improve with Tylenol.

Rationale: Persistent sore throat with Group A Strep. Pharyngitis is a common symptom.

3. Tongue with strawberry patches.

Rationale: This sign suggests palatal petechiae, that is common with Group. A Streptococcus Pharyngitis.

4. Lymphadenopathy on palpation.

Rationale: Strep. Pharyngitis is associated with cervical lymphadenopathy.

5. Fatigue.

Rationale: General fatigue and malaise is common in patients who have Group A Streptococcal infections.

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This study source was downloaded by 100000766549104 from CourseHero.com on 09-10-2022 15:02:16 GMT -05:00

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This study source was downloaded by 100000766549104 from CourseHero.com on 09-10-2022 15:02:16 GMT -05:00
https://www.coursehero.com/file/151720676/CASE-STUDY-JULIA-2-3docx/
This study source was downloaded by 100000766549104 from CourseHero.com on 09-10-2022 15:02:16 GMT -05:00
https://www.coursehero.com/file/151720676/CASE-STUDY-JULIA-2-3docx/

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