elderly patient presents with altered mental status and turns out they have Urinary infection as the cause ..family can be historian for presenting history
Written Case Narrative – Individual Work
During the course of the semester you will complete a Case Narrative. The case narrative will utilize an actual /or potential patient that is relevant to the Educator or specific APRN role of the student. The student will follow the outline provided for this narrative.
1. Summary of a common diseases/illnesses seen in a selected body system 20%
2. Pertinent subjective data
3. Pertinent objective data
4. Diagnosis with differential (Include pathophysiology of the specific diagnosis, as well as diagnostic tests and labs needed to confirm)
5. Management plan, including Rx, education, prevention, and follow-up (Discuss the pharmacokinetic and pharmacodynamics of the drug treatment)
6. Guidelines and research pertinent to disease
7. References. You will need a minimum of 5 references that are less than 5 years old. You may use your textbook as one of the references. If the references are websites, they must be recognized research based sites, for example – Centers for Disease Control, American College of Obstetricians, etc and not consumer webpages. You must have at least one peer reviewed research article.
Be written like a history and physical rather than a research paper. There are sections of the paper that you will expand to include the additional information requested.
• Summary of a common diseases/illnesses seen in a selected body system
• Patient information – presenting chief complaint
• Pertinent subjective data
o Relate subjective data to diagnosis
• Pertinent objective data
o Relate physical exam findings to diagnosis
• Differential Diagnosis List – all possible in order of most likely to least likely – state why.
o Include pathophysiology of the final diagnosis
o Diagnostic tests and labs needed to confirm the diagnosis – also relate how it ruled out other diagnosis
o Sensitivity and Specificity of tests used
o Cost and availability
• Management plan, including Rx, education, prevention, and follow-up (Discuss the pharmacokinetic and pharmacodynamics of the drug treatment)
• Guidelines and research pertinent to disease
These bullets points should be the heading for your paper.
For example, “Mr. G is a 54 year-old man with a history of coronary heart disease who presents with 3 hours of crushing substernal chest pressure.