CASE STUDY 3

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Copy the template for ROS and PE from Bates verbatim and substitute normal for abnormal findings listed in the case studies. If the finding is normal put “denies”. If it is abnormal put “endorses”.

 

Use the pocket manual for differential diagnosis to look up your symptoms (presenting) and they will list possible causes. Narrow the causes down based on 1)your patient’s presenting symptoms and 2) by using the current medical diagnosis and treatment textbook.

 

Create a genogram for the family history. Example is in Bates.

 

Look at the case study rubric and make sure you’ve met all requirements.

 

Pertinent positive: sign/symptom that helps to rule in diagnosis.

 

Pertinent negative: sign/symptom that is NOT present and because it is not present helps to rule out an alternate diagnosis.

 

For example, pertinent positives for pneumonia could be fever and cough with blood-tinged sputum. These could also be pertinent positives for TB but if the patient does NOT have night sweats and weight loss for example, the absence of these symptoms would be pertinent negatives that would make you think the patient is more likely experiencing pneumonia (rule out TB).

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