Case Study Question – What is diagnosis and how would you proceed?

Case: Ms. Johnson is a 61-year-old woman presenting today with a chief complaint of a hand tremor that has worsened over the past three years. The tremor occurs when she uses her hands for activities such as slicing vegetables, sewing, putting on her lipstick, or typing at her computer. Her handwriting has become messy and sprawling and very difficult to read. She has worked for 23 years as an executive assistant; as a result of her tremor and the associated difficulties, she is considering retirement. She notes that on the rare occasion that she consumes alcohol, the tremor is somewhat improved.

Family history is positive for two grandparents who also “had the shakes” later in life. She assumes that they both had Parkinson’s disease and is afraid “that’s what’s wrong with me, too.”

Medications include an antihypertensive, a statin, and an estrogen patch. Today her BP is 120/62. Height is 5’6”, weight 139 lbs. On physical examination, mental status, cranial nerves, sensation, muscle strength, tone, and deep tendon reflexes are all normal. There is a mild tremor bilaterally in both hands as she writes her name. No tremor at rest. There is no bradykinesia or rigidity noted. Voice is somewhat tremulous. There is a slight involuntary back-and-forth horizontal rotation of the head.

Lab data, including lipids, TSH and FBS are all within normal limits.

What is your diagnosis and how would you proceed?

Student is presented with a medical case study scenario.

Student will then be asked to create a case study report with 6 content area subheadings. Make sure you answer all the questions comprehensively. Use complete sentences.

1. Diagnosis Name
What is the name of the disease/disorder?

2. Explanation
What are the reasons for your diagnosis?|

3. Causes/Risk Factors
What are some of the factors that put this patient at risk for the disease?
What other questions might you have for the patient that would provide you with more data?

4. Clinical Manifestation
Describe the clinical features of the disease that are present in the individual.

5. Diagnostic Procedures
What types of procedures were done on the patient and what were the results?
Are there other diagnostic procedures that you would like to have performed? If so, which ones and why?

6. Treatment

Describe the treatment plan that you would prescribe for this patient.

Here is an example of a scenario:

J.O. is a 62-year-old man who comes into the clinic because he has been suffering from headaches and problems with his vision. In addition, he complains about frequent urination and increased thirst. Other medical problems include obesity and hypothyroidism. He has a history of heavy alcohol use but quit drinking alcohol 2 years ago.

Physical exam reveals a height of 5 feet, 8 inches, weight of 243 lb, blood pressure of 160/100 mmHg, and a regular pulse of 84 beats/min. There is no retinopathy or thyromegaly. There is no clinical evidence of congestive heart failure or peripheral vascular disease.

Laboratory evaluation reveals trace protein on urinalysis, blood urea nitrogen of 14 mg/dl, serum creatinine of 1.2 mg/dl, random serum glucose of 265 mg/dl, normal electrolytes, and normal thyroid-stimulating hormone levels. A 24-h urine collection reveals a urinary albumin excretion rate of 250 mg/day.

Overall
Case Report

Organization, Creativity, Engaging

Excellent
(5 pts)

Case Study is excellent, extremely organized, interesting, creative, and easy to follow. Demonstrates originality.

Good
(4 pts)

Presentation is clear and understandable, interesting, and organized.

Fair
(3 pts)

Case Study is fairly organized, slightly engaging.

Poor
(2 – 1 pts)

Case Study is unclear, unorganized, unengaging, difficult to follow.

(-) Effort
(no pts received)

Did not submit material for grading.

Content

1. Diagnosis Name

2. Explanation

3. Causes/Risk Factors

4. Clinical Manifestation

5. Diagnostic Procedures

6. Treatment

Excellent

Case Study thoroughly covers all 6 content requirements. Information presented is accurate and appropriately related.

Good

Case Study covers 5 -6 content areas accurately.

Fair

Case Study covers 3-5 content areas. Inaccurate information is minimal.

Poor

Case Study covers 1-2 content areas with inaccuracies and a lack of thoroughness.

(-) Effort

No content areas were covered in this case study, or all information presented was inaccurate.

 
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