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Posted: April 5th, 2018

Nursing case study Pathophysiology Written Report

Case Study 1
Case Studies for Written Report

John is a 47 year old male who presents to his GP with sudden onset, severe pain to his right big toe. He reports that last night he was woken by the pain, which felt like “burning, being on fire”, and when he looked at it, the toe was red, hot, swollen and so sore he couldn’t touch it, and had to try to return to sleep with his foot stuck out from the covers because even the weight of the blanket was “intolerable”. John reports he took Paracetamol last night and this morning, but the pain is barely muted, and he came into the clinic wearing open toed sandals, because he “couldn’t get his foot into a shoe”. John did spend the night “out with the boys”, and admits to being drunk, but he can’t specifically remember if he kicked anything or hurt his foot, but he also can’t rule that out (due to his high level of intoxication).
John’s past medical history includes:
• High cholesterol
• High blood pressure
• Transient Ischaemic Attack three months ago, with no residual effects
• No recollection of previous swelling of the joints, hands nor feet • nor chronic joint pain
John’s current medications includes:
• Hydrochlorothiazide 25 mg with dinner
• Aspirin 325 mg with breakfast
• Lipitor 10 mg at night
John’s family history includes:
• Mum is still alive, with Type 2 Diabetes
No recollection of
acute
• Dad died at 68 yo due to osteosarcoma
• No siblings
• Married and divorced twice o Two children from each marriage o All adults, and apparently healthy
John’s social history includes:
• Non-smoker
• No illicit drug use
• Heavy drinker of alcohol, 5 – 6 drinks per day, and more on the weekends
• Socialises often with “the boys”
• Diet of “meat and three veg”
• Little exercise
Physical Examination:
Page 1 of 12
91530 PP2 Document
• White male, 47 yo, acute, mild distress (discomfort)
• Height 6’ 1” (185 cm)
• Weight 102 kg
• Blood Pressure 145/85
• Heart Rate 92 bpm
• Respiration Rate 17 per minute
• Temperature 37oC
• Right first metatarsophalangeal joint = hot, swollen, erythematous, tender to touch
Questions:
Q.1) Patient (Case Study) Outline (maximum 150 words)
Quick summary of your Case Study. Link it to your introduction and your “discussion/conclusion” (ie the rest of your report).

Q.2 ) Critical Analysis – What is your diagnosis? (maximum 400 words)
Identify, state, explain and justify your “initial” diagnosis of the patient under study; including other conditions that may present in similar ways. Then, state and justify your “final” (differential) diagnosis of what condition (pathophysiology) is affecting the presenting patient, including clinical test results (if relevant).

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