NUR 638 – CASE STUDY FORMAT

CC: (6yo male with cough X 1 week)

HPI – history of contemporary sickness. Right here is subjective records that the patient or parent is telling you about the sickness. It’s a ways the “memoir” of why the patient is coming to peep you, consist of one thing else that’s connected (resembling co-morbidities).

Example: 5yo female with history of asthma brought to the clinic by mom for c/o cough for five days, worse at night. Cough sounds barky. Mom also stories the patient is wheezing and in need of breath when enticing in activity. Also has a runny nostril and sore throat. Had a fever of 102 the day long past by however none on the present time. Cough is worse at night. Ingesting correctly, urinating generally. Siblings are also sick.

PMH – past clinical history (consist of gestation, ie. prematurity and provide complications if pertinent)

Surgical history

Family history

Medicines (name of medication, dose, indication) employ prescriptive layout

Immunizations

Social or Home disaster – who carry out they are living with, siblings, pets (pertinent for respiratory or hypersensitive response complaints), smoking. For the correctly talk over with you should well presumably presumably stride over the developmental milestones.

ROS-review of methods: review all of the pertinent physique methods (even in case you lined it within the HPI). For the correctly talk over with, you are going to wish to carry out an total ROS.

Physical examination: total if a correctly dinky one, pertinent methods for a particular criticism. Nonetheless, EVERY patient should have a Respiratory and Cardiovascular review. You will consist of important indicators and the outcomes of any diagnostic testing.

Contain age appropriate developmental review, including milestones and phases.

Differential Diagnoses: What disease carry out you factor in is causing the indicators? List your vital or working diagnosis first. Contain 3 differentials with supporting pathology. That it is seemingly you’ll build pertinent positives and negatives to give a take hold of to your diagnosis.

Opinion of Care: Contain all the pieces that you just should well carry out for this patient. Medicines, written in prescriptive layout (dose, route, frequency, interval, indication). Any lab work or diagnostic testing that you just should well expose. Non pharmacologic therapies. Patient teaching including issues the patient can carry out to forestall disease transmission, indicators that you just would decide the patient to survey for and what to carry out if they happen. Be aware up instructions – including a time-frame and who/where they should switch. Take into consideration for your Neatly Talk over with you are going to wish to debate anticipatory guidance!

Reference your sources the employ of APA layout. Exercise your developed apply journal article for pathophysiology or therapy plot records for the diagnosis.

Be aware the grading rubric. Practically all these case stories will be long. As continuously, keep up a correspondence to your assigned college in case you should well need any questions.

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