Case study

PICK ONE BELOW 

1. Jim is a 69-year-old male who comes in today complaining of dyspnea on exertion, and you have noted that he has gained about 25 pounds since his last visit 7 months ago. He tells you that he is not sleeping at night because of a constant cough, and he thinks he has a cold because he is coughing up pink frothy “spit”. He is extremely fatigued because of his lack of sleep.  Your examination reveals bilateral 3+ pitting edema with his lower extremities being cool to the touch, distended abdomen, hepatomegaly, hacking cough, and S3 with a gallop. Jim had a myocardial infarction (MI) 15 years ago, and his currently on medication for hypertension.
2. Matthew is a 52-year-old truck driver who is seeing you today for his physical. He states that he has been in his usual state of health but missed his physical for the past few years.  His BP is 165/90, HR 90, Height is 6’2, and Weight is 204. Total Cholesterol 244, HDL 32 LDL 166 Triglycerides 344 A1C 6.8.
3. Jennifer is an 84-year-old who recently returned from London with her husband. She comes to your clinic as a walk-in from the airport because she does not feel well. She has felt shaky, a little short of breath, and slightly light-headed for the past 2 to 3 hours. She did not take her Norvasc or Lisinopril this morning because she didn’t feel well. She presents to you slightly diaphoretic. Her BP is 90/50, HR is 155, and RR 20. She is alert and oriented.

Case Study Chosen: (List what case you have chosen)

Demographics: Age/Gender

SUBJECTIVE

• CC:
• HPI: (As listed from Case Study Information)
• Subjective: (What questions will you ask? Must be listed by System, ONLY as it

pertains to Chief Complaint/HPI. Should NOT be all systems or full head to toe unless
pertinent).

OBJECTIVE

General:

• VS BP, HR, RR, Weight, Height, BMI
• Physical Exam Elements: (Must be listed by System, ONLY as it pertains to Chief

Complaint/HPI. Should NOT be all systems or full head to toe unless pertinent.)
• POC Testing (any Point of Care (POC) testing specifically performed in the office):

What tests (if any) did you perform during the visit (urine dip, rapid strep, urine pregnancy
test, Glucose finger-stick, etc.)? Leave blank if none.

ASSESSMENT

• Working Diagnosis: (Must include ICD 10)
• Differential Diagnosis:

PLAN

• Diagnostic studies: If any, will be ordered (Labs, X-ray, CT, etc.). Only include if you will
be ordering for your patient. Remember the importance of appropriate resource utilization.
Remember you are managing this patient in the CLINIC setting, NOT THE HOSPITAL.

• Treatment: Must include full Sig/Order for all prescriptions and OTC meds (Name of
medication, dosage, frequency, duration, number of tabs, number of refills). CANNOT only
list drug class. Should follow evidence-based guidelines.

• Referrals: If Applicable
• Education:
• Health maintenance:
• RTC:

Diagnosis Signs/Symptoms Gold Standard
Diagnostics

Gold Standard
Treatment

Congestive Heart
Failure

Unstable Angina

SVT
(Supraventricular
Tachycardia)

HTN

Hyperlipidemia

Acute Coronary
Syndrome

Atrial Fibrillation

Deep Vein
Thrombosis

Dissecting Aortic
Aneurysm

Peripheral Artery
Disease (PAD)