7 2 Case Studies Student’s Name Institutional Affiliation Course Name and Number

7

2 Case Studies

Student’s Name

Institutional Affiliation

Course Name and Number

Instructor’s Name

Date

2 Case Studies

Case Study 1: Nervous System

Chief Complaint

“I have been experiencing pain in the right lower jaw and submandibular area for the last 2 weeks.”

History of Present Illness (HPI)

This is a 64-year-old female patient who presents with pain in the right lower jaw. The patient reports that the pain started two weeks after the tooth implant procedure (O). The pain presents in her lower jaw and submandibular area (L). The patient states that the pain has lasted for two weeks (D). The patient describes the pain as burning and stabbing, usually mimicking an electric shock pain (C). The pain increases after washing her face or brushing her teeth (A). She also reports no relieving factors (R). Usually, the patient’s pain is sporadic, lasting for several minutes. She states that the pain has been progressively worsening and is now occurring several times a day (T). The patient rates her pain as 10/10 when it occurs (S).

Past Medical History

The patient has a history of hypothyroidism, currently being controlled by levothyroxine 75 mcg, 1 tablet daily. She also has a history of anxiety, currently being controlled by fluoxetine 20 mg, 1 tablet daily. Besides, she has impaired hearing in the right ear. Her surgical history is characterized by a recent tooth implant. In terms of immunizations, the patient is up-to-date with her immunizations. These included a flu shot and a mammogram, which was negative.

Social History

Occupation: homemaking.

Substance use: No history of smoking or alcohol use.

Constitutional Symptoms: Patient denies fever, chills, or night sweats.

Physical exam: Vital signs: BP: 118/70 mm/Hg, temperature: 98.7°F, pulse: 72 beats/minute.

Review of Systems (ROS)

Head: the patient reports experiencing right lower jaw pain. She, however, denies experiencing headaches.

Eyes: the patient does not have an eye discharge. She also wears glasses and his last eye exam was 6 months ago.

Ears: the patient denies ear discharge. The patient reports impaired hearing in the right ear.

Nose: the patient does not experience nasal congestion.

Mouth and throat: the patient reports pain when brushing her teeth and a recent tooth implant.

Psychiatric: the patient has a history of anxiety.

Respiratory: the patient does not experience coughing, wheezing, or dyspnea.

Neurological: the patient does not experience headaches, numbness, or weakness in the face.

Gastrointestinal: the patient does not experience nausea or vomiting.

Cardiovascular: the patient does not have SOB, chest pain, or cardiovascular issues.

Endocrine: the patient has a history of hypothyroidism. She denies experiencing night sweats.

Integumentary: the patient does not have wounds, cuts, or experience itching. Assessment: upon examination, the patient’s skin moisture is normal. She also has a healthy skin turgor.

Musculoskeletal: the patient occasionally experiences sporadic jaw pain. She, however, did not experience falls in the past year.

Hematological/Lymphatic: the patient does not experience easy bruising, bleeding, or have swollen lymph nodes.

Allergic/immunological: the patient does not have any type of allergic reaction to drugs, food, or environmental allergens.

Unique populations: the patient does not experience falls related to her old age.

Case Study 2: Blood in the Stool

Chief Complaint

“Blood in stool.”

History of Present Illness (HPI)

Onset: The patient, a 52-year-old woman, presented with rectal bleeding, which started 4 months ago.

Location: The patient’s bleeding occurs in the rectal area. She states that the bleeding is associated with bowel movements.

Duration: The patient states that the rectal bleeding initially occurred once a week during her bowel movement. The bleeding has been ongoing for the past 4 months, occurring every day.

Character: The 52-year-old woman describes her rectal bleeding as characterized by dark red blood, approximately 1 teaspoon, which is usually mixed with stool.

Aggravating factors: The patient’s rectal bleeding occurs with all bowel movements, which are regular every day.

Relieving factors: The patient uses over-the-counter hemorrhoid cream daily, albeit it does not provide relief.

Timing: the rectal bleeding initially occurred once a week. Even so, it has been occurring once every day for the past 4 months.

Severity: The patient describes the blood as about 1 teaspoon. She does not explicitly quantify the severity.

Past Medical History: The patient has a history of obesity, hypothyroidism, and internal hemorrhoids. Her history of internal hemorrhoids dates back to the birth of her daughter 20 years ago. The internal hemorrhoids resulted in rare bleeding, which improves with the use of OTC hemorrhoid cream. The patient’s obesity started during her pregnancy at the age of 32, with her hypothyroidism diagnosis coming later. She reports using levothyroxine 112 mcg daily for 20 years to control her hypothyroidism. She also states that she does not have a history of heart, lung, bleeding disorders, prior surgeries, or hospitalizations.

Family History: Parents: alive and healthy; in their 70s. Maternal grandmother: deceased; believed to have died of “some kind of stomach cancer.” No family history of bleeding disorder, heart disease, and diabetes.

Social History: The patient is in a stable marriage. She is also sexually active. Besides, the patient does not smoke or use recreational drugs. She, however, takes two glasses of wine every night with dinner.

Constitutional Symptoms: the patient reports fatigue, weight loss of about 12 pounds over the past four months attributed to dieting, and occasional night sweats, which she attributes to menopause. However, the patient denies having any fever or chills.

Review of Systems (ROS)

Head: the patient does not experience headaches. She, however, experiences dizziness after standing up quickly.

Eyes: the patient does not experience vision or eye problems.

Ears: the patient does not experience ear irritation or changes in hearing.

Nose: the patient does not experience sneezing or nasal congestion.

Mouth and Throat: the patient denies trouble swallowing or a sore throat.

Cardiovascular: the patient reports shortness of breath.

Musculoskeletal: the patient denies joint or muscle pain.

Respiratory: the patient does not experience coughing, wheezing, or coughing up blood.

Gastrointestinal: the patient reports rectal bleeding but denies heartburn, nausea, vomiting, diarrhea, or black, tarry stools.

Genitourinary: the patient has no issues with blood in her urine, vaginal discharge or bleeding, painful urination, or pelvic pain.

Endocrine: the patient denies hypothyroidism.

Psychiatric: the patient denies anxiety, depression, or insomnia.

Hematological/Lymphatic: the patient denies bruising or swollen lymph nodes.

Allergic/Immunological: patient denies food, medication, or environmental allergies.

Neurological: the patient denies any weakness or numbness.

Unique Populations: there are no concerns related to her age, which is 52 years old.