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?
CASE STUDY REPORT – BIOL 164 General Outline
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.
Case Study Rubric for
BIOL 164: Human Anatomy and Physiology
Overall
Case
Report
Organizati
on,
Creativity,
Engaging
Excellent
(5 pts)
Good
(4 pts)
Fair
(3 pts)
Poor
(2 – 1 pts)
(-) Effort
(no pts received
Case Study is
excellent,
extremely
organized,
interesting,
creative, and
easy to follow.
Demonstrates
originality.
Presentation
is clear and
understanda
ble,
interesting,
and
organized.
Case
Study is
fairly
organized,
slightly
engaging.
Case Study
is unclear,
unorganize
d,
unengaging
, difficult to
follow.
Did not submit m
grading.
Content
Excellent
Good
Fair
Poor
(-) Effort
Case Study
covers 5 -6
content areas
accurately.
Case
Study
covers 3-5
content
areas.
Inaccurate
information
is minimal.
Case Study
covers 1-2
content
areas with
inaccuracie
s and a lack
of
thoroughne
ss.
No content area
in this case stud
information pres
inaccurate.
1.
Diagnosis
Name
Case Study
thoroughly
covers all 6
content
2.
requirements.
Explanatio Information
n
presented is
accurate and
3.
appropriately
Causes/Ri related.
sk Factors
4. Clinical
Manifestat
ion
5.
Diagnostic
Procedure
s
6.
Treatment
Purchase answer to see full
attachment