CASE STUDY INSTRUCTIONS

CASE STUDY INSTRUCTIONS

DEFINITION

A case study is a report of the presentation of a disease process using a specific patient as the focus for the report and discussion.

GUIDELINES

The case study has been designed to challenge your clinical thinking and enhance your learning as well as receive credit. The information gathering process will likely require: acquisition of textbook, electronic and journal resources. Your task is to assimilate the information into a case study report. This report will be in presentation form and likely include figures/charts/tables. It should follow the format listed below:

Introduction

Introduce the patient and your interest in them and their disease process

Why is this disease process of interest?

History

History of present illness (HPI)

Details about the disease process as outlined above:

Duration, course, symptoms, treatments, progression, factors which appear to influence the disease process

Past medical history (PMH)

Medications, allergies, other illnesses, hospitalizations, surgery

Social history (SH)

Education, employment, religious and cultural beliefs/practices, support system especially as they relate to the disease process

Family history (FH)

Specifically family diseases and health problems which seem to have a relationship to the patients disease process

Physical Exam

While all organs and systems should be examined, areas affected by the patients disease process should be described in detail

Vital signs

Neurological

HEENT

Lymph nodes

Neck

Back

Breast only if affected by the disease process

Lungs

Heart and peripheral vascular

Abdomen

Genital urinary only if affected by the disease process

Extremities

Musculoskeletal

Skin

Laboratory/Testing

Names and results of all diagnostic testing should be reported

Labs, radiographs, MRI, ultrasound, CT, neurological studies, special tests/evaluations

Discussion This should be the main section of the case study

Diagnosis/Assessment

The known or working diagnosis should be stated with an explanation/description of the findings and data which support the diagnosis

This section should include cited/references information about the disease process, evaluation and treatment

The patients findings should be compared to that provided in your references

Management/Treatment

This section is a description of the interventions, therapies and medications employed to address the patients disease process

These may be prescribed, complimentary or nontraditional modalities

If further evaluation or reassessment is necessary, the reasons and results should be described

Cited/referenced information on the management of the disease process should be included in the discussion

A comparison should be made between cited recommendations and the management of your patient with an explanation of any variances

Course and Prognosis

The course of the patients disease, response to above management and prognosis for improvement/recovery is discussed in this section

Details about the results/responses, side effects and complications related to management/treatment and the course of the disease should be provided

Plans for further treatment and evaluations should be discussed with explanations and citations/references where available

Referenced information on the patients prognosis should be included here with comparisons to your patient

Future Investigation

Here is where you pose questions, discuss missing/unknown information and provide recommendations

You should pose/discuss questions you have about the disease process and its management, and how these questions might be answered

You should also provide recommendations for further evaluation, treatment, or management with supporting arguments and/or citations/references

Summary

This is where you summarize the patient, their disease process, the patients current status and your recommendations for the future

Citations/References

All published sources of information are to be referenced

Figures/Tables/Photos

A picture is worth a thousand words.

Photos, figured, diagrams, and tables which enhance your case study should be numbered, referred to and included where applicable in the presentation