- Choose a patient (If you are not currently in clinical practice, you may choose a patient from a case study book.)
- Summarize their case presentation in 1-2 pages.
- Use the following format:
xx year old ethnicity-gender admitted (to ER/for surgery/etc.)
Briefly describe the medical plan of care
Include past medical history and results of pertinent lab and diagnostic tests
Include a list of all medications
- Choose one disease process and describe the pathophysiology and expected signs and symptoms, and lab/dx tests. THEN compare the general description to the patient presented above.
For example, in iron deficiency anemia, patients typically have low MCV/MCH levels and experience the classic signs and symptoms of anemia: pallor, lightheadedness, DOE, and fatigue as well as compensatory sympathetic response (pallor, tachycardia, elevated BP, increased respirations, nausea). They may also experience chelitis and pica. Look at your patient. Did they experience these things? If you realize you’re missing data, just say so.
- What medications are usually used to treat the disease process in #4? Is the patient on any of them? Are there any drugs the patient is on that might be used off label for this illness? What is the therapeutic goal? What are the major adverse effects? Is the patient experiencing any?
So going with our example above, patients would usually be on some form of iron. This particular patient is on Ferrous Sulfate 325mg TID. Therapeutic goal is increase in RGB, HGB, HCT, MCV, MCH, and an early sign of improvement is increased reticulocytes. This patient had high reticulocytes, but all other values were still low, so she is probably in the early stages of recovery.
Main adverse effects are GI, including upset, constipation, dark stools. The patient didn’t complain about anything, and I did not ask her. Maybe, I should have.
Are there any diseases the patient has that your chosen disease process may interact with? How?
As an example: the patient also has COPD. This impact the ability to deliver oxygen to the blood. Because the blood doesn’t have enough red blood cells, her respiratory symptoms may be worse than usual. (Fatigue, DOE)
Length is far less important than analysis. I do NOT need pages of what the disease looks like. I need a paragraph or two summarizing the main issues and symptoms. Then RELAiquTE it to the patient