case study

I’m stuck on a Writing question and need an explanation.

For this Discussion, you will take on the role of a clinician who is building a health history for one of the following cases. Your instructor will assign you your case number.

Case 1 Case 2 Case 3
Chief Complaint
(CC)
“It burns when I urinate” “I had a severe headache yesterday with difficulty to speak” “I have been having frequents headaches lately”
History of Present Illness (HPI) A 68-year-old Caucasian male who reports to have increase on the frequency of urination with urgency for the last 5 days. He also present dysuria and nocturia. A 64-year-old African American female who reports having a severe pulsatile diffuse headache yesterday with sudden difficulty to talk with last for about two hours. She did not seek medical attention. This morning she woke up with no problems but is here today due her husband advise. A 25-year-old Hispanic female presents to your clinic with a headache located on right temporal area, pulsatile.
PMH Benning prostatic hyperplasia diagnosed 3 years ago, UTI 6 months ago, Lithotripsy left kidney 10 years ago. No issues after treatment Atrial Fibrillation, Hypertension. Is allergic to Non-steroidal Anti-inflammatory drugs Aspirin Frequent headaches since I was 15, with menses.
Drug Hx Rosuvastatin 20 mg
Olmesartan 20 mg
Losartan 50 mg
Xarelto 15 mg BID
Ibuprofen for Headaches
Subjective
Fever and chills, no changes in vision or hearing, no difficulty chewing or swallowing. No sexually active, nocturia, dysuria.
Yellowish urethral secretion.
Feels Palpitations, joint pain with yesterday’s episode Light makes headache worst Nausea associated with headaches. No vomiting, Headaches improve usually with rest, ibuprofen, and sleep, but it is annoying to have to sleep all-day
Objective Data
VS B/P 150/96; Pulse 89; RR 16; Temp 99.4; Ht 6,1; wt 180; B/P 131/80; temperature 98.2°F; (RR) 18; (HR) 84, irregular; oxygen saturation (PO2) 96%; B/P 108/64; Pulse 86; RR 16; Temp 98.6;
General well-developed male, no acute distress well-developed female, no acute distress 25-year-old female appears well developed and well-nourished, healthy appearing, wearing dark glasses in a dim room
HEENT Atraumatic, normocephalic, PERRLA, EOMI, arcus senilus bilaterally, conjunctiva and sclera clear, nares patent, nasopharynx clear, edentulous. Atraumatic, normocephalic, PERRLA, EOMI, conjunctiva and sclera clear; nares patent, nasopharynx clear, good dentition. no injection, anicteric, PERRLA, EOMs intact, without pain to movement; normal vision
Lungs CTA AP&L CTA AP&L CTA AP&L
Card S1S2 without rub or gallop S4 present Irregular heart beat with normal rate S1S2 without rub or gallop
Abd No tenderness normoactive bowel sounds x 4; No tenderness normoactive bowel sounds x 4;

benign, normoactive bowel sounds x 4;

Rectal exam Warm, swollen and painful prostate gland Non contributory Non contributory
Integument good skin turgor noted, moist mucous membranes intact without lesions masses or rashes. intact without lesions masses or rashes.
Neuro No obvious deformities, CN grossly intact II-XII No obvious deficits and CN grossly intact II-XII Cranial nerves II to XII intact; sensation intact, DTRs 2+ throughout.
Functional neurological exam is WNL

Once you received your case number, answer the following questions:

  1. What other subjective data would you obtain?
  2. What other objective findings would you look for?
  3. What diagnostic exams do you want to order?
  4. Name 3 differential diagnoses based on this patient presenting symptoms?
  5. Give rationales for your each differential diagnosis.
  6. What teachings will you provide?

Submission Instructions:

  • Your instructor will assign you your case number and you will post on the case number you have been assigned.
  • You will reply to the other two case studies (One of each).
  • Your initial post should be at least 500 words, formatted and cited in current APA style with support from at least 2 academic sources. Your initial post is worth 8 points.
  • You should respond to at least two of your peers by extending, refuting/correcting, or adding additional nuance to their posts. Your reply posts are worth 2 points (1 point per response.)
  • All replies must be constructive and use literature where possible.

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Grading Rubric


Your assignment will be graded according to the grading rubric.

Discussion Rubric
Criteria Ratings Points

Identification of Main Issues, Problems, and Concepts

5 points
Distinguished

Identify and demonstrate a sophisticated understanding of the issues, problems, and concepts.

4 points
Excellent

Identifies and demonstrates an accomplished understanding of most of the issues, problems, and concepts.

2 points
Fair

Identifies and demonstrates an acceptable understanding of most of the issues, problems, and concepts.

1 point
Poor

Identifies and demonstrates an unacceptable understanding of most issues, problems, and concepts.

5 points

Use of Citations, Writing Mechanics and APA Formatting Guidelines

3 points
Distinguished

Effectively uses the literature and other resources to inform their work. Exceptional use of citations and extended referencing. High level of APA precision and free of grammar and spelling errors.

2 points
Excellent

Effectively uses the literature and other resources to inform their work. Moderate use of citations and extended referencing. Moderate level of APA precision and free of grammar and spelling errors.

1 point
Fair

Ineffectively uses the literature and other resources to inform their work. Moderate use of citations and extended referencing. APA style and writing mechanics need more precision and attention to detail.

0 point
Poor

Ineffectively uses the literature and other resources to inform their work. Unacceptable use of citations and extended referencing. APA style and writing mechanics need serious attention.

3 points
Response to Posts of Peers

2 points
Distinguished

The student constructively responded to two other posts and either extended, expanded, or provided a rebuttal to each.

1 point
Fair

The student constructively responded to one other post and either extended, expanded, or provided a rebuttal.

0 point
Poor

The student provided no response to a peer’s post.

2 points

Prof. Angela

4.6/5

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