Pathophysiology
In order to write a case study paper, you must carefully address a number of sections in a specific order with specific information contained in each. The guideline below outlines each of those sections.
Section
Information to Include
Introduction (patient and problem)
Explain who the patient is (Age, gender, etc.)
Explain what the problem is (What was he/she diagnosed with, or what happened?)
Introduce your main argument (What should you as a nurse focus on or do?)
Pathophysiology
Explain the disease (What are the symptoms? What causes it?)
History
Explain what health problems the patient has (Has she/he been diagnosed with other diseases?)
Detail any and all previous treatments (Has she/he had any prior surgeries or is he/she on medication?)
Nursing Physical Assessment
List all the patient’s health stats in sentences with specific numbers/levels (Blood pressure, bowel sounds, ambulation, etc.)
Related Treatments
Explain what treatments the patient is receiving because of his/her disease
Nursing Diagnosis & Patient Goal
Explain what your nursing diagnosis is (What is the main problem for this patient? What need to be addressed?)
Explain what your goal is for helping the patient recover (What do you want to change for the patient?)
Nursing Interventions
Explain how you will accomplish your nursing goals, and support this with citations (Reference the literature)
Evaluation
Explain how effective the nursing intervention was (What happened after your nursing intervention? Did the patient get better?)
Recommendations
Explain what the patient or nurse should do in the future to continue recovery/improvement
Background and Physical Examination
J. P. is a 46-year-old man presents to the emergency department with a 5-day history of progressively worsening breathlessness on exertion and mild, general flulike symptoms. He also complains about night sweats and an intermittent low-grade fever, both of which started about 2 weeks ago.
Upon physical examination, the patient does not appear to be in any acute distress. His vital signs are measured as a pulse of 89 beats/min, blood pressure of 140/85 mm Hg, and a respiratory rate of 19 breaths/min. He is afebrile, with a temperature of 99.8°F (37.7°C).
The chest examination reveals nothing out of the ordinary, and his cardiovascular and respiratory examinations, including auscultation, are unremarkable. The abdominal examination reveals no fluid thrill, shifting dullness, or bruit. The liver and the spleen are not enlarged. No lymph nodes are palpable.
Multiple areas of hyperpigmentation are noted; otherwise, the skin inspection is unremarkable, with no hematomas, bruises, wounds, or scars noted. Electrocardiography (ECG) reveals a sinus rhythm with a heart rate of 84 beats/min, and the T waves are somewhat flattened in leads V1, aVL, and III, but they are otherwise unremarkable.
Laboratory Test Results and Other Findings
Significant laboratory findings include a white blood cell count of 9.1 x 103/µL (9.1 x 109/L; reference range, 3.5-8.8 x 109/L), a platelet count of 429 x 103/μL (429 x 109/L; reference range, 140-350 109/L), a C-reactive protein level of 91 mg/L (reference range, < 10 mg/L), a lactate dehydrogenase (LDH) level of 4.7 microkatals (µkat)/L (reference range, < 3.5 µkat/L), an erythrocyte sedimentation rate (ESR) of 30 mm (reference range, 1-12 mm), and a D-dimer of 2.2 mg/L (reference range, < 0.25 mg/L).
A spiral CT scan is performed, which shows no pulmonary embolism. It does, however, reveal the presence of a significant pericardial effusion (1 cm ventral x 2.5 cm dorsal) and a multilobular substernal mass occupying the anterior superior mediastinum that is about 2.5 cm in thickness and 7 cm in length, with high absorption. Additionally, the mediastinal lymph nodes are enlarged; some are as large as 2 cm in size. No other pertinent findings on spiral CT are reported.
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