Chief Complaint

A 22 year old male comes to the student health center clinic with complaints of RUQ pain for 48 hours, accompanied by nausea and anorexia. Pain started 8 hours after a drinking binge 2 days ago (approximately one-half liter of vodka). Pain has been worsening over the past 2 days from a 2 to 5 on the pain scale. There was vomiting twice the morning after the binge, but no vomiting since. Patient reports emesis was clear/yellow with no blood and denies diarrhea. Patient has had this pain only one other time some months ago after drinking too much, but it was less severe and went away fairly quickly without any treatment. Patient is very concerned about this pain lasting so long. He is not sleeping at night due to the pain and worry over the cause. Patient admits to drinking binges approximately two times per week for the past 2 years. He denies stress from schoolwork or social relationships but states he has an anxiety disorder with panic attacks. He has only had a short course of Ativan given at the ER, about a year ago. He deals with the panic /anxiety attacks with marijuana or just “rides it out”.

Past Medical History

• Denies surgeries or serious illnesses/hospitalizations

• No regular medications; had previously been on SSRI but has not been for a couple of years

Family History

• Father, age 55, Parkinson’s disease

• Mother, age 52, HTN

• No history of ETOH/drug abuse or mental illness in the patient or family

Psychosocial History

Considers health to be good. Usually eats well and exercises five times per week lifting weights. ETOH abuse as above, recreational marijuana use. Doing well in his classes (senior majoring in International Business). Reports being in a monogamous relationship for the past 2 years, no use of condoms. 

Review of Systems

• General: Denies fever or weight loss but has been unable to eat much over the past couple of days due to abdominal pain and nausea.

• HEENT: Denies HA, visual changes, redness or yellow color of the eyes. Has blackouts related to ETOH abuse.

• CV: Experiences chest tightness with panic/anxiety attacks. Denies chest pain, HTN, hypotension, palpations

• Respiratory: Experiences SOB with panic/anxiety attacks. No SOB while lifting weights. No history of asthma or allergies. Does not smoke cigarettes or chew tobacco. 

• GI: See above under CC. Denies epigastric pain or pain in the RLQ or LLQ. No history of PUD or H. pylori. No rectal bleeding or melena.

• MS: Denies joint pain or swelling. Has pain in the right back but believes it is related to the RUQ pain. 

• GU: Denies frequency, dysuria, hematuria. No history of renal calculi. No penile discharge. No hx of STIs.

• Neuro: Blackouts with drinking. Denies HA, head injuries, dizziness, or balance difficulties except with ETOH.

• Endocrine: Denies polyuria, polydipsia, polyphagia. No heat or cold intolerances. No weight loss or gain.

• Hematology: Denies anemia, bleeding, easy bruising.

• Psychiatric: C/O panic/anxiety attacks. Reports that attacks started in high school without any specific precipitating event. Stressful situations exacerbate the attacks, but they sometimes come on without an obvious cause. 

Physical Examination

• Vital signs: T 97.6, BP 150/80, HR 72, RR 18. O2 saturation 99% HT 72, WT 180 lbs.

• General: Appearance visibly anxious with sweat beads on forehead and nose.

• HEENT: Sclera non-icteric. PERRLA, no exophthalmos or lid lag. TMs with good light reflex, no inflammation. Posterior pharynx not inflamed, no cervical lymphadenopathy. Thyroid not enlarged or nodular. 

• CV: RR&R without murmurs, S3, S4, splits, rubs. No lower extremity edema. No carotid bruits.

• Lungs: Respiratory rate even, unlabored. No adventitious sounds.

• Abdomen: BS present in four quadrants. No aortic or renal bruits. RUQ tender on palpation. Liver percusses 6 cm in MCL. No rebound tenderness. Right CVA tenderness on percussion. No RLQ tenderness, negative psoas sign, negative obturator sign, negative McBurney’s sign. No epigastric tenderness. Stool guiac negative. 

• MS: No joint swelling or tenderness. Full ROM all joints. No chest wall tenderness but states that RUQ pain increases with bending forward and lying down. Strength 5/5 in all four extremities.

• GU: Negative for hernia, testicular masses, penile lesions, or discharge. 

Questions

1. What three conditions would be considered in your differential diagnosis, with most likely condition listed first (provide rationale)?

2. What further history, further reexamination, and diagnostic studies are warranted to evaluate your differential diagnosis?

3. What further evaluation or work up should be done for this patient?

4. What is the final diagnosis?

All Questions in Case Study Answered Correctly	10
Introduction & Background: Give the reader a description/scenario of the patient in the case study. Since this is worth 20 points please make sure you have at least 3-4 well-structured paragraphs.	15
Pathophysiology: Discuss the pathophysiology related to your final diagnosis for this patient. Since this is worth 15 points please make sure you have at least 3-4 well-structured paragraphs.	15
Diagnostics & Labs: Identify all possible lab and other diagnostic tests which could be potentially ordered in the care of patient.	10
Treatment Plan: discuss appropriate treatments (pharmacologic and non-pharmacologic) regimens and interventions	15
Conclusion & Articles: Identify a minimum of two peer-reviewed evidence based article that support your treatment/care plan. Summarize your case and treatment plan in a 1-2 paragraph conclusion/summary	15
APA format: title page & reference page. Please review APA 6th edition for what is expected in an APA 6th ed. paper. Proper use of grammar and clarity of writing style to include spell check.	10
References: Cites in AP format throughout paper to include a minimum of three peer-reviewed evidence based practice nursing journals.	10
Total:	100

Case Study & Care Plan Grade Rubric

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