Case 7

You are instructed to see Mrs. Dolores Darling, a 50-year-old security guard. She has not seen a

physician in 5 years. Recently, she went to a health fair and, after a free blood pressure check, was told

to see a physician for possible high blood pressure. Your name was in her managed care book, so she

made an appointment to see you. This is her first visit.

Vital Signs: Temperature 98.6°F Blood pressure 150/95 mmHg Heart rate 80 beats per minute

Respiratory rate 12 breaths per minute You enter the examination room and see an obese female (210

pounds with a height of 63 inches). She is in no distress.

Examinee’s Tasks

1. Obtain a focused and relevant history.

2. Perform a focused and relevant physical examination.

3. Discuss your initial diagnostic impressions with the patient.

4. Discuss follow-up tests with the patient.

5. After seeing the patient, complete paperwork relevant to the case.

GUIDELINES FOR INDIVIDUAL CASE STUDY

Required elements of the case study:

All papers are to be type written, double spaced, with pages numbered. Please write course name and

number, your name, and date clearly on materials submitted. Use American Psychological Association

(APA) style 6 th edition including paper format and references. Points may be deducted for multiple

spelling, grammar, format and typing errors.

1. Subjective (0.5 point)

State the patient’s chief complaint, reason for visit and/or the problem for which the patient

sought consultation.

a. All symptoms related to the problem are described using the following cue descriptive

categories:

1) Precipitating/alleviating factors (including prescribed and/or self-remedies and their

effect on the problem).

2) Associated symptoms

3) Quality of all reported symptoms including the effect on the patient’s lifestyle

4) Temporal factors (date of onset, frequency, duration, sequence of events)

5) Location (localized or generalized? does it radiate?)

6) Sequelae (complications, impact on patient and/or significant other)

7) Severity of the symptoms

b. Past Medical History including immunizations, allergies, accidents, illnesses, operations,

hospitalizations.

c. Family History includes family members’ health history.

d. Social history to include habits, residence, financial situation, outside assistance, family

inter-relationships.

e. Review of Systems relevant to the chief complaint/presenting problem is included. Include

pertinent positives and negatives.

2. Objective (0.5 point)

a. Using inspection, palpation, percussion, and auscultation, the examiner evaluates all

systems associated with the subjective complaint including all systems which may be

causing the problem or which will manifest or may potentially manifest complications and

records positive and pertinent negative findings

b. Performs appropriate diagnostic studies if equipment is available

c. Records results of pertinent, previously obtained diagnostic studies.

d. Use Handout Guidelines to Physical Examination.

3. Assessment (1.5 points)

a. Diagnosis/es with pathophysiology is (are) derived from the subjective and objective data

b. Differential diagnoses with pathophysiology are prioritized

c. Diagnosis/es come(s) from the medical and/or nursing domain

d. Assessment includes health risks/needs assessment

4. Plan (1.5 points)

a. Appropriate diagnostic studies with rationale

b. Therapeutic treatment plan with rationale

c. Was this patient appropriate for a nurse practitioner as a provider? Is consultation or

collaboration with another health care provider required?

d. Health promotion/disease prevention carried out or planned: education, discussion,

handouts given, evidence of patient’s understanding.

e. What community resources are available in the provision of care for this client?

f. Referrals initiated (including to whom the patient is referred to and the purpose)

g. Target dates for re-evaluating the results of the plan and follow up

5. Other (1 point)

a. Information is typed, double-spaced, 12 pt. font, and concise (using short paragraphs and

phrases)

b. Information is written so that the objective reader can follow the progression of events and

information

c. Only standard, accepted medical terminology and abbreviations are used.

d. At least four (4) references from recent professional journal publications are required for

each (APA format). These can include but not limited to medical, research,

pharmacological or advanced practice nursing journals. More than 4 references should be

used.

e. Rationales need to include a clear demonstration of the use of evidence-based practice in

decision-making. Risks and benefits as well as how an intervention was determined to be

evidence-based will be clear to the reader.

f. Rationales need to include a clear demonstration of the use of evidence-based practice in

decision-making. Risks and benefits as well as how an intervention was determined to be

evidence-based will be clear to the reader.