Case Study Summary

Construct a case study summary from the assigned case study and record your summation.

At the conclusion of the summary answer the following questions:

• What are the components of an effective oral case presentation and which did you use in your summary?
• Which of the NONPF core competencies are you demonstrating in summarizing the case?

Case Description

CC: difficulty swallowing

HPI: 32-yr-old female with a 5-day history of runny nose, sore throat, congestion and cough. The symptom that bothers her the most is the cough because it wakes her up at night.  She denies smoking. She drinks a class of wine at diner about 4 days a week. She is married and has 2 children age 5 and 8. Her 5 year-old came home about a week ago with a “cold”.  She denies a history of asthma and allergies. She adds that since she is here she would like a refill on her SSRI. Her mood is “fine”.[unique_solution]

PMH
Denies chronic diseases
Denies surgeries
GYN: LMP (2 weeks ago) G 2 P 2 live full term vaginal deliveries
Denies STIs ever, HIV test 12/08 negative, last pap 1 year ago negative results, does self breast exam monthly

Diet: vegetarian
Sleep 8 hours a night
Exercise: goes to the Y 4-x week Zumba Class

Social: college degree, occupation administrative assistant, home owner and lives with husband and two children, bi-lingual English and Spanish, no religious affiliation. No advance directive completed. She has a history of arrest for “Pot” in High School. She denies guilty plea and explains it was her brother’s stash but she could not tell anybody at the time. It has been erased from her record.

Last Dental appointment 4 months ago, gets teeth cleaned 2-x year, brushes and floss twice a day.

ROS:
General: Denies weight loss, fever, fatigue, chills
Skin: denies skin rashes, moles recent changes, + blistering sunburn in childhood
H: denies trauma
E: no glasses, pain, trauma, discharge
E: no problems with hearing, pain, discharge
N/Oral: see HPI
N: denies history problems with Thyroid, no enlarged lymph nodes, no pain
Pul: + cough, no history asthma, smoke cigarette no/never see HPI
CV: denies history heart murmur, heart problems
GI: denies N/V/D last BM today AM soft brown no blood
GYN/GU: denies vaginal discharge, pain, one sex partner husband monogamous relationship
MS: denies pain, injury, problems with joints
Ext: denies edema
Neuro: denies headache, history of seizure

Exam:  Ht 5’ 2” Wt: 105 BP  100/60  HR 96 RR 14 Temp: 99.9

Gen: WNWD White female alert and anxious, coughing during interview
Skin: pink, warm, dry, no rashes
HEENT: Sclera clear, EMO’s intact, PERRLA, TMs grey, canal clear bilaterally
Oral: Pharynx erythematous, tonsils + 2 bilateral uvula Uvula midline, good dentition, no order, buccal membranes moist pink no lesions
Neck: no thyroid enlargement or nodules, full ROM, nontender no carotid bruits
Pul: course breath sounds bilaterally, no wheezing, no increase fremitus
CV: RRR S1 S2 no S3 or S4 no murmur
GI: Abd flat, nontender, BS + throughout, no bruits, no organomegaly
GU/GYN: not examined
MS: not examined
Neuro: CN 2 – 12 intact DTRs +2 bilaterally
Mood: anxious

Labs: Rapid Strep test negative

Assessment: Viral URI/Bronchitis

Plan:
Diagnostics: None
Rx: Robitussin with Codeine 1 – 2 teaspoons every 4 hours as needed for cough
120 cc No Refills
Education: warm beverages or soups, tea with lemon, for sore throat, good hand washing, Motrin or Tylenol for fever, push fluids, can use OTC Sudafed as needed for runny nose
F/U: Return in 1 week if symptoms persists or get worse