Comprehensive Case Study – Diagnostic and Treatment Management Plan

 


Dvelop and submit a comprehensive, evidence-based case study analyzing a
complex patient presentation. This assignment demonstrates your ability to collect and
synthesize clinical data, formulate accurate differential diagnoses, and implement a
patient-centered treatment plan grounded in current practice guidelines.
Case Study Requirements:
1. Patient Scenario (Real or Simulated):
• Age, sex, race/ethnicity
• Chief complaint (CC)
• History of Present Illness (HPI)
• Past Medical History (PMH)
• Family History (FH)
• Social History (SH)• Review of Systems (ROS)
• Physical Examination Findings (PE)
2. Differential Diagnosis:
• List at least 3 differential diagnoses
• Justify each differential using:
o Presenting signs/symptoms
o Pathophysiology
o Risk factors
o Diagnostic criteria
3. Final Diagnosis:
• Identify the most likely diagnosis
• Explain the rationale
• Cite at least two current evidence-based guidelines or scholarly sources
4. Diagnostic Workup Plan:
• Labs, imaging, or additional testing
• Provide rationale for each
• 5. Treatment & Management Plan:
• Non-pharmacologic interventions
• Patient education
• Follow-up and referrals, if needed
• 6. Cultural, Ethical, or Socioeconomic Considerations:
• Address any relevant patient-specific factors that influence care
• 7. Evaluation of Outcomes:
• How will you measure the effectiveness of your treatment plan?
• Short- and long-term follow-up goals

 

 

 

Sample Answer

 

 

 

 

 

 

 

 

Simulated Case Study: Unexplained Weight Loss and Fatigue

 

Scenario Disclaimer: This case study is entirely simulated for educational purposes and does not represent a real patient. Medical decisions should only be made by qualified healthcare professionals.

 

1. Patient Scenario

 

Age, Sex, Race/Ethnicity: 68-year-old female, Black/African American

Chief Complaint (CC): "I've been feeling so tired and losing weight without trying for the past three months."

History of Present Illness (HPI): Ms. J, a 68-year-old Black female, presents with a 3-month history of progressive fatigue and unintentional weight loss. She estimates a weight loss of approximately 15 lbs (from 160 lbs to 145 lbs) over this period, without changes in diet or exercise. She reports constant, generalized fatigue that interferes with her daily activities, making it difficult to perform household chores or engage in her usual social activities. She denies fever, chills, night sweats, changes in appetite (though she sometimes feels full quickly), nausea, vomiting, diarrhea, constipation, abdominal pain, chest pain, shortness of breath, cough, new skin rashes, muscle weakness, or joint pain. She has noticed occasional dizziness upon standing quickly. She attributes her decreased energy to "just getting old" but is now concerned by the persistent weight loss.